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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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-…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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 …
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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 …
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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.…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…

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