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  1. Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation. | PSNet

    psnet.ahrq.gov/issue/anatomy-failure-sociotechnical-evaluation-laboratory-physician-order-entry-system
    April 13, 2022 - Study Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation. Citation Text: Peute LW, Aarts J, Bakker PJM, et al. Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation. Int J…

  2. Does the patient's payer matter in hospital patient safety?: a study of urban hospitals. | PSNet

    psnet.ahrq.gov/issue/does-patients-payer-matter-hospital-patient-safety-study-urban-hospitals
    November 05, 2008 - Study Does the patient's payer matter in hospital patient safety?: a study of urban hospitals. Citation Text: Clement JP, Lindrooth R, Chukmaitov AS, et al. Does the patient's payer matter in hospital patient safety?: a study of urban hospitals. Med Care. 2007;45(2):131-8. Copy Citat…

  3. Risk factors for hospital admissions associated with adverse drug events. | PSNet

    psnet.ahrq.gov/issue/risk-factors-hospital-admissions-associated-adverse-drug-events
    October 18, 2018 - Study Risk factors for hospital admissions associated with adverse drug events. Citation Text: Kongkaew C, Hann M, Mandal J, et al. Risk factors for hospital admissions associated with adverse drug events. Pharmacotherapy. 2013;33(8):827-37. doi:10.1002/phar.1287. Copy Citation Fo…

  4. The Joint Commission's ongoing professional practice evaluation process: costly, ineffective, and potentially harmful to safety culture. | PSNet

    psnet.ahrq.gov/issue/joint-commissions-ongoing-professional-practice-evaluation-process-costly-ineffective-and
    July 01, 2017 - Study The Joint Commission's ongoing professional practice evaluation process: costly, ineffective, and potentially harmful to safety culture. Citation Text: Donnelly LF, Podberesky DJ, Towbin AJ, et al. The Joint Commission's ongoing professional practice evaluation process: costly, ine…

  5. Follow-up Visits for Children Who Are Obese or Overweight with a Weight-Related Comorbidity: Table 4 (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0242-table4.pdf
    January 01, 2010 - Follow-up Visits for Children Who Are Obese or Overweight with a Weight-Related Comorbidity: Table 4 Table 4: Evidence for Follow-up Visits for Children Who Are Overweight Type of Evidence Key Findings Level of Evidence (USPSTF Ranking*) Citations Expert recommendation The complexity of tre…

  6. Why didn't you call me? Factors junior learners consider when deciding whether to call their supervisor. | PSNet

    psnet.ahrq.gov/issue/why-didnt-you-call-me-factors-junior-learners-consider-when-deciding-whether-call-their
    July 14, 2021 - Study Why didn't you call me? Factors junior learners consider when deciding whether to call their supervisor. Citation Text: Alibhai KM, Zabolotniuk TR, Raîche I, et al. Why didn't you call me? Factors junior learners consider when deciding whether to call their supervisor. J Surg Educ.…

  7. CHIPRA 230: Technical Specifications (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-230-tech-specs.pdf
    June 02, 2025 - CHIPRA 230: Technical Specifications 1 The percentage of children, ages 2 through 17 years old, who had documentation of BMI percentile and documentation of weight classification at an outpatient care visit during the measurement year. A higher proportion indicates better performance. This mea…

  8. Prevalence of error-prone abbreviations used in medication prescribing for hospitalised patients: multi-hospital evaluation. | PSNet

    psnet.ahrq.gov/issue/prevalence-error-prone-abbreviations-used-medication-prescribing-hospitalised-patients-multi
    July 06, 2011 - Study Prevalence of error-prone abbreviations used in medication prescribing for hospitalised patients: multi-hospital evaluation. Citation Text: Dooley MJ, Wiseman M, Gu G. Prevalence of error-prone abbreviations used in medication prescribing for hospitalised patients: multi-hospital …

  9. Opioids prescribed after low-risk surgical procedures in the United States, 2004–2012. | PSNet

    psnet.ahrq.gov/issue/opioids-prescribed-after-low-risk-surgical-procedures-united-states-2004-2012
    May 29, 2024 - Study Opioids prescribed after low-risk surgical procedures in the United States, 2004–2012. Citation Text: Wunsch H, Wijeysundera DN, Passarella MA, et al. Opioids Prescribed After Low-Risk Surgical Procedures in the United States, 2004-2012. JAMA. 2016;315(15):1654-7. doi:10.1001/jama.…

  10. CHIPRA 213: Section 2 Technical Specifications (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-213-section-2-tech-specs.pdf
    June 02, 2025 - CHIPRA 213: Section 2 Technical Specifications The percentage of children identified as having Sickle Cell Anemia who received anticipatory guidance regarding the risks and benefits of treatment with hydroxyurea as part of outpatient care during the measurement year. A higher proportion indicates b…

  11. Recognizing quality improvement and patient safety activities in academic promotion in departments of medicine: innovative language in promotion criteria. | PSNet

    psnet.ahrq.gov/issue/recognizing-quality-improvement-and-patient-safety-activities-academic-promotion-departments
    April 20, 2011 - Study Recognizing quality improvement and patient safety activities in academic promotion in departments of medicine: innovative language in promotion criteria. Citation Text: Staiger TO, Mills LM, Wong BM, et al. Recognizing Quality Improvement and Patient Safety Activities in Academic …

  12. Defining a high-quality and effective morbidity and mortality conference: a systematic review. | PSNet

    psnet.ahrq.gov/issue/defining-high-quality-and-effective-morbidity-and-mortality-conference-systematic-review
    September 30, 2012 - Review Defining a high-quality and effective morbidity and mortality conference: a systematic review. Citation Text: Beaulieu-Jones BR, Wilson S, Howard DS, et al. Defining a high-quality and effective morbidity and mortality conference: a systematic review. JAMA Surg. 2023;158(12):1336-…

  13. Preanalytical errors in primary healthcare: a questionnaire study of information search procedures, test request management and test tube labelling. | PSNet

    psnet.ahrq.gov/issue/preanalytical-errors-primary-healthcare-questionnaire-study-information-search-procedures
    July 07, 2010 - Study Preanalytical errors in primary healthcare: a questionnaire study of information search procedures, test request management and test tube labelling. Citation Text: Söderberg J, Brulin C, Grankvist K, et al. Preanalytical errors in primary healthcare: a questionnaire study of info…

  14. Patient misidentifications caused by errors in standard barcode technology. | PSNet

    psnet.ahrq.gov/issue/patient-misidentifications-caused-errors-standard-barcode-technology
    June 13, 2012 - Study Patient misidentifications caused by errors in standard barcode technology. Citation Text: Snyder ML, Carter A, Jenkins K, et al. Patient misidentifications caused by errors in standard bar code technology. Clin Chem. 2010;56(10):1554-60. doi:10.1373/clinchem.2010.150094. Copy …

  15. Meaningful Use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population with diabetes. | PSNet

    psnet.ahrq.gov/issue/meaningful-use-stage-2-e-prescribing-threshold-and-adverse-drug-events-medicare-part-d
    July 05, 2017 - Study Meaningful Use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population with diabetes. Citation Text: Powers C, Gabriel MH, Encinosa W, et al. Meaningful use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population w…

  16. Clinical decision support as a prevention tool for medication errors in the operating room: a retrospective cross-sectional study. | PSNet

    psnet.ahrq.gov/issue/clinical-decision-support-prevention-tool-medication-errors-operating-room-retrospective
    July 05, 2023 - Study Clinical decision support as a prevention tool for medication errors in the operating room: a retrospective cross-sectional study. Citation Text: Amici LD, van Pelt M, Mylott L, et al. Clinical decision support as a prevention tool for medication errors in the operating room: a ret…

  17. Quality assessment of spontaneous triggered adverse event reports received by the Food and Drug Administration. | PSNet

    psnet.ahrq.gov/issue/quality-assessment-spontaneous-triggered-adverse-event-reports-received-food-and-drug
    August 07, 2024 - Study Quality assessment of spontaneous triggered adverse event reports received by the Food and Drug Administration. Citation Text: Brajovic S, Piazza-Hepp T, Swartz L, et al. Quality assessment of spontaneous triggered adverse event reports received by the Food and Drug Administratio…

  18. Establishing a multi-institutional quality and patient safety consortium: collaboration across affiliates in a community-based medical school. | PSNet

    psnet.ahrq.gov/issue/establishing-multi-institutional-quality-and-patient-safety-consortium-collaboration-across
    June 24, 2009 - Commentary Establishing a multi-institutional quality and patient safety consortium: collaboration across affiliates in a community-based medical school. Citation Text: Hillman E, Paul J, Neustadt M, et al. Establishing a multi-institutional quality and patient safety consortium: collab…

  19. A lethal hidden curriculum—death of a medical student from opioid use disorder. | PSNet

    psnet.ahrq.gov/issue/lethal-hidden-curriculum-death-medical-student-opioid-use-disorder
    October 19, 2022 - Commentary A lethal hidden curriculum—death of a medical student from opioid use disorder. Citation Text: Lucey CR, Jones L, Eastburn A. A Lethal Hidden Curriculum - Death of a Medical Student from Opioid Use Disorder. N Engl J Med. 2019;381(9):793-795. doi:10.1056/NEJMp1901537. Copy C…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33810/psn-pdf
    June 01, 2016 - Becoming a Certified Professional in Patient Safety—A Registered Nurse's Perspective June 1, 2016 Frank K. Becoming a Certified Professional in Patient Safety—A Registered Nurse's Perspective. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-registered-nurse…
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