-
psnet.ahrq.gov/node/74691/psn-pdf
January 01, 2021 - Quality (AHRQ) funded study is looking at the incidence of
diagnostic error in inpatient settings, examining
-
psnet.ahrq.gov/web-mm/near-miss-bedside-medications
February 01, 2006 - Benefits of studying near misses
Studying close calls has several advantages over examining either
-
psnet.ahrq.gov/issue/pathology-and-patient-safety-critical-role-pathology-informatics-error-reduction-and-quality
July 20, 2009 - Resources From the Same Author(s)
Database construction for improving patient safety by examining
-
psnet.ahrq.gov/issue/does-your-knee-make-more-click-or-clack-teaching-car-talk-new-docs
April 17, 2019 - November 4, 2014
Examining the diagnostic justification abilities of fourth-year medical
-
psnet.ahrq.gov/node/45654/psn-pdf
July 11, 2017 - Hospital prescribing of opioids to Medicare beneficiaries.
July 11, 2017
Jena AB, Goldman D, Karaca-Mandic P. Hospital Prescribing of Opioids to Medicare Beneficiaries. JAMA
Intern Med. 2016;176(7):990-7. doi:10.1001/jamainternmed.2016.2737.
https://psnet.ahrq.gov/issue/hospital-prescribing-opioids-medicare-benefic…
-
psnet.ahrq.gov/node/43887/psn-pdf
April 08, 2018 - Types of diagnostic errors in neurological emergencies in
the emergency department.
April 8, 2018
Dubosh NM, Edlow JA, Lefton M, et al. Types of diagnostic errors in neurological emergencies in the
emergency department. Diagnosis (Berl). 2015;2(1):21-28. doi:10.1515/dx-2014-0040.
https://psnet.ahrq.gov/issue/types…
-
psnet.ahrq.gov/node/847731/psn-pdf
April 19, 2023 - Lessons from health care leaders: rethinking and
reinvesting in patient safety.
April 19, 2023
doi:10.1056/CAT.23.0090.
https://psnet.ahrq.gov/issue/lessons-health-care-leaders-rethinking-and-reinvesting-patient-safety
Progress in patient safety has been disappointingly slow. This commentary shares thoughts from a…
-
psnet.ahrq.gov/node/47940/psn-pdf
May 01, 2019 - Validation of the Primary Care Patient Measure of Safety
(PC PMOS) questionnaire.
May 1, 2019
Giles SJ, Parveen S, Hernan AL. Validation of the Primary Care Patient Measure of Safety (PC PMOS)
questionnaire. BMJ Qual Saf. 2019;28(5):389-396. doi:10.1136/bmjqs-2018-007988.
https://psnet.ahrq.gov/issue/validation-pr…
-
psnet.ahrq.gov/node/43236/psn-pdf
August 02, 2015 - Hospital safety scores: do grades really matter?
August 2, 2015
Gonzalez AA, Ghaferi AA. Hospital Safety Scores: do grades really matter? JAMA Surg. 2014;149(5):413-
4.
https://psnet.ahrq.gov/issue/hospital-safety-scores-do-grades-really-matter
This editorial examines whether The Leapfrog Group's Hospital Safety S…
-
psnet.ahrq.gov/node/36251/psn-pdf
September 13, 2006 - Frequency and type of errors and near errors reported by
critical care nurses.
September 13, 2006
Balas MC; Scott LD; Rogers AE.
https://psnet.ahrq.gov/issue/frequency-and-type-errors-and-near-errors-reported-critical-care-nurses
Prior research has demonstrated that intensive care unit patients are particularly vu…
-
psnet.ahrq.gov/node/35108/psn-pdf
April 06, 2011 - Improving medication management for patients: the effect
of a pharmacist on post-admission ward rounds.
April 6, 2011
Fertleman M, Barnett N, Patel T. Improving medication management for patients: the effect of a pharmacist
on post-admission ward rounds. Qual Saf Health Care. 2005;14(3):207-11.
https://psnet.ahrq.…
-
psnet.ahrq.gov/node/42582/psn-pdf
September 18, 2013 - When diagnostic testing leads to harm: a new outcomes-
based approach for laboratory medicine.
September 18, 2013
Epner PL, Gans JE, Graber ML. When diagnostic testing leads to harm: a new outcomes-based approach
for laboratory medicine. BMJ Qual Saf. 2013;22 Suppl 2:ii6-ii10. doi:10.1136/bmjqs-2012-001621.
https:…
-
psnet.ahrq.gov/node/836834/psn-pdf
March 30, 2022 - Dying for Care.
March 30, 2022
Stein L, Fraser J, Penzenstadler N et al. USA Today. March 10, 2022.
https://psnet.ahrq.gov/issue/dying-care
Nursing home residents, staff, and care processes were particularly vulnerable to COVID-19. This
collection of resources examines data and documentation involving one nursing …
-
psnet.ahrq.gov/node/45551/psn-pdf
November 30, 2016 - Parents' perspectives on "keeping their children safe" in
the hospital.
November 30, 2016
Rosenberg RE, Rosenfeld P, Williams E, et al. Parents' Perspectives on "Keeping Their Children Safe" in
the Hospital. J Nurs Care Qual. 2016;31(4):318-326. doi:10.1097/NCQ.0000000000000193.
https://psnet.ahrq.gov/issue/parent…
-
psnet.ahrq.gov/node/46804/psn-pdf
January 01, 2021 - Retained guidewires in the Veterans Health
Administration: getting to the root of the problem.
May 9, 2018
Cherara L, Sculli GL, Paull DE, et al. Retained Guidewires in the Veterans Health Administration: Getting to
the Root of the Problem. J Patient Saf. 2021;17(8):e991-e928. doi:10.1097/PTS.0000000000000475.
htt…
-
psnet.ahrq.gov/node/35583/psn-pdf
June 17, 2010 - Using a bar-coded medication administration system to
prevent medication errors in a community hospital
network.
June 17, 2010
Sakowski J, Leonard T, Colburn S, et al. Using a bar-coded medication administration system to prevent
medication errors in a community hospital network. American Journal of Health-System …
-
psnet.ahrq.gov/node/47114/psn-pdf
October 13, 2018 - Focused ethnography of diagnosis in academic medical
centers.
October 13, 2018
Chopra V, Harrod M, Winter S, et al. Focused Ethnography of Diagnosis in Academic Medical Centers. J
Hosp Med. 2018;13(10):668-672. doi:10.12788/jhm.2966.
https://psnet.ahrq.gov/issue/focused-ethnography-diagnosis-academic-medical-cente…
-
psnet.ahrq.gov/node/72537/psn-pdf
December 02, 2020 - Automation failures and patient safety.
December 2, 2020
Ruskin KJ, Ruskin AC, O’Connor M. Automation failures and patient safety. Curr Opin Anaesthesiol.
2020;33(6):788-792. doi:10.1097/aco.0000000000000935.
https://psnet.ahrq.gov/issue/automation-failures-and-patient-safety
Task automation in medicine is a core …
-
psnet.ahrq.gov/node/47779/psn-pdf
June 12, 2019 - Medication accuracy in electronic health records for
microbial keratitis.
June 12, 2019
Ashfaq HA, Lester CA, Ballouz D, et al. Medication Accuracy in Electronic Health Records for Microbial
Keratitis. JAMA Ophthalmal. 2019;137(8):929-931. doi:10.1001/jamaophthalmol.2019.1444.
https://psnet.ahrq.gov/issue/medicati…
-
psnet.ahrq.gov/node/44358/psn-pdf
September 24, 2016 - Interruptions and medication administration in critical
care.
September 24, 2016
Bower R, Jackson C, Manning JC. Interruptions and medication administration in critical care. Nurs Crit
Care. 2015;20(4):183-95. doi:10.1111/nicc.12185.
https://psnet.ahrq.gov/issue/interruptions-and-medication-administration-critical…