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psnet.ahrq.gov/node/41557/psn-pdf
August 01, 2012 - Signal and noise: applying a laboratory trigger tool to
identify adverse drug events among primary care
patients.
August 1, 2012
Brenner S, Detz A, Lopez A, et al. Signal and noise: applying a laboratory trigger tool to identify adverse
drug events among primary care patients. BMJ Qual Saf. 2012;21(8):670-5. doi:1…
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psnet.ahrq.gov/node/46507/psn-pdf
October 11, 2017 - Outcomes in two Massachusetts hospital systems give
reason for optimism about communication-and-resolution
programs.
October 11, 2017
Mello MM, Kachalia A, Roche S, et al. Outcomes In Two Massachusetts Hospital Systems Give Reason
For Optimism About Communication-And-Resolution Programs. Health Aff (Millwood). 201…
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psnet.ahrq.gov/node/42628/psn-pdf
January 07, 2015 - Engaging patients in medication reconciliation via a
patient portal following hospital discharge.
January 7, 2015
Heyworth L, Paquin AM, Clark J, et al. Engaging patients in medication reconciliation via a patient portal
following hospital discharge. J Am Med Inform Assoc. 2014;21(e1):e157-62. doi:10.1136/amiajnl-2…
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psnet.ahrq.gov/node/50368/psn-pdf
September 25, 2019 - A patient and family reporting system for perceived
ambulatory note mistakes: experience at 3 U.S. healthcare
centers.
September 25, 2019
Bourgeois FC, Fossa A, Gerard M, et al. A patient and family reporting system for perceived ambulatory
note mistakes: experience at 3 U.S. healthcare centers. J Am Med Inform As…
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psnet.ahrq.gov/node/39947/psn-pdf
July 03, 2014 - Association between implementation of a medical team
training program and surgical mortality.
July 3, 2014
Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training
program and surgical mortality. JAMA. 2010;304(15):1693-1700. doi:10.1001/jama.2010.1506.
https://psnet.ahrq…
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psnet.ahrq.gov/node/47742/psn-pdf
February 20, 2019 - AHRQ Nursing Home Survey on Patient Safety Culture:
2019 User Comparative Database Report.
February 20, 2019
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality;
February 2019. AHRQ Publication No. 19-0027-EF.
https://psnet.ahrq.gov/issue/ahrq-nursing-home-survey-patient-…
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psnet.ahrq.gov/node/40904/psn-pdf
January 04, 2012 - Effect of illness severity and comorbidity on patient
safety and adverse events.
January 4, 2012
Naessens JM, Campbell CR, Shah ND, et al. Effect of illness severity and comorbidity on patient safety
and adverse events. Am J Med Qual. 2012;27(1):48-57. doi:10.1177/1062860611413456.
https://psnet.ahrq.gov/issue/eff…
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psnet.ahrq.gov/node/38399/psn-pdf
February 11, 2009 - Effect of computerized provider order entry with clinical
decision support on adverse drug events in the long-term
care setting.
February 11, 2009
Gurwitz JH, Field T, Rochon P, et al. Effect of computerized provider order entry with clinical decision
support on adverse drug events in the long-term care setting. J…
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psnet.ahrq.gov/node/44958/psn-pdf
March 09, 2016 - The Sepsis Early Recognition and Response Initiative
(SERRI).
March 9, 2016
Jones SL, Ashton CM, Kiehne L, et al. The Sepsis Early Recognition and Response Initiative (SERRI). Jt
Comm J Qual Patient Saf. 2016;42(3):122-138.
https://psnet.ahrq.gov/issue/sepsis-early-recognition-and-response-initiative-serri
Early …
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psnet.ahrq.gov/node/46394/psn-pdf
August 29, 2018 - Sustained user engagement in health information
technology: the long road from implementation to system
optimization of computerized physician order entry and
clinical decision support systems for prescribing in
hospitals in England.
August 29, 2018
Cresswell K, Lee L, Mozaffar H, et al. Sustained User Engagement…
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psnet.ahrq.gov/node/40995/psn-pdf
January 04, 2012 - Effects of the introduction of the WHO "Surgical Safety
Checklist" on in-hospital mortality: a cohort study.
January 4, 2012
van Klei WA, Hoff RG, van Aarnhem EEHL, et al. Effects of the introduction of the WHO "Surgical Safety
Checklist" on in-hospital mortality: a cohort study. Ann Surg. 2012;255(1):44-9.
doi:10…
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psnet.ahrq.gov/node/45302/psn-pdf
November 28, 2016 - Patients and families as teachers: a mixed methods
assessment of a collaborative learning model for medical
error disclosure and prevention.
November 28, 2016
Langer T, Martinez W, Browning DM, et al. Patients and families as teachers: a mixed methods
assessment of a collaborative learning model for medical error …
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psnet.ahrq.gov/node/41964/psn-pdf
April 17, 2013 - Use of HIT for adverse event reporting in nursing homes:
barriers and facilitators.
April 17, 2013
Wagner LM, Castle NG, Handler S. Use of HIT for adverse event reporting in nursing homes: barriers and
facilitators. Geriatr Nurs. 2013;34(2):112-5. doi:10.1016/j.gerinurse.2012.10.003.
https://psnet.ahrq.gov/issue/u…
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psnet.ahrq.gov/node/44845/psn-pdf
July 01, 2016 - Is single room hospital accommodation associated with
differences in healthcare-associated infection, falls,
pressure ulcers or medication errors? A natural
experiment with non-equivalent controls.
July 1, 2016
Simon M, Maben J, Murrells T, et al. Is single room hospital accommodation associated with differences i…
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psnet.ahrq.gov/node/42924/psn-pdf
April 24, 2014 - Role-modeling and medical error disclosure: a national
survey of trainees.
April 24, 2014
Martinez W, Hickson GB, Miller BM, et al. Role-modeling and medical error disclosure: a national survey of
trainees. Acad Med. 2014;89(3):482-9. doi:10.1097/ACM.0000000000000156.
https://psnet.ahrq.gov/issue/role-modeling-and…
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psnet.ahrq.gov/node/42923/psn-pdf
September 26, 2017 - Assessing the state of safe medication practices using
the ISMP Medication Safety Self Assessment for
Hospitals: 2000 and 2011.
September 26, 2017
Vaida AJ, Lamis RL, Smetzer JL, et al. Assessing the State of Safe Medication Practices Using the ISMP
Medication Safety Self Assessment ® for Hospitals: 2000 and 2011.…
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psnet.ahrq.gov/node/865532/psn-pdf
April 10, 2024 - Let us to the TWISST; Plan, Simulate, Study and Act.
April 10, 2024
Colman N, Hebbar KB. Let us to the TWISST; Plan, Simulate, Study and Act. Pediatr Qual Saf.
2023;8(4):e664. doi:10.1097/pq9.0000000000000664.
https://psnet.ahrq.gov/innovation/let-us-twisst-plan-simulate-study-and-act
In situ simulation can identi…
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psnet.ahrq.gov/node/39104/psn-pdf
February 16, 2011 - Is there a relationship between high-quality performance
in major teaching hospitals and residents' knowledge of
quality and patient safety?
February 16, 2011
Pingleton SK, Horak BJ, Davis DA, et al. Is there a relationship between high-quality performance in major
teaching hospitals and residents' knowledge of qu…
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psnet.ahrq.gov/node/45310/psn-pdf
January 03, 2017 - Minding the gaps: assessing communication outcomes of
electronic preconsultation exchange.
January 3, 2017
Price EL, Sewell JL, Chen AH, et al. Minding the Gaps: Assessing Communication Outcomes of Electronic
Preconsultation Exchange. Jt Comm J Qual Patient Saf. 2016;42(8):341-54.
https://psnet.ahrq.gov/issue/mind…
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psnet.ahrq.gov/node/33592/psn-pdf
December 15, 2024 - Adverse Events, Near Misses, and Errors
December 15, 2024
Adverse Events, Near Misses, and Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current re…