-
psnet.ahrq.gov/node/837608/psn-pdf
September 06, 2023 - Harm Caused by Delays in Transferring Patients to the
Right Place of Care.
September 6, 2023
Farnborough, UK: Healthcare Safety Investigation Branch; August 2023.
https://psnet.ahrq.gov/issue/harm-caused-delays-transferring-patients-right-place-care
Handoffs between prehospital emergency medical services (EMS) pro…
-
psnet.ahrq.gov/node/845078/psn-pdf
February 22, 2023 - Maternal and Infant Health Inequality: New Evidence from
Linked Administrative Data.
February 22, 2023
Kennedy-Moulton K, Miller S, Persson P, et al. Cambridge, MA: National Bureau of Economic
Research; 2022. NBER Working Paper No. 30693.
https://psnet.ahrq.gov/issue/maternal-and-infant-health-inequality-new-…
-
psnet.ahrq.gov/node/73396/psn-pdf
June 16, 2021 - The impact of the built environment on patient falls in
hospital rooms: an integrative review.
June 16, 2021
Pati D, Valipoor S, Lorusso L, et al. The impact of the built environment on patient falls in hospital rooms:
an integrative review. J Patient Saf. 2021;17(4):273-281. doi:10.1097/pts.0000000000000613.
http…
-
psnet.ahrq.gov/node/847058/psn-pdf
April 05, 2023 - Care Delivery within Community Mental Health Teams.
April 5, 2023
Farnborough, UK: Healthcare Safety Investigation Branch; March 2023.
https://psnet.ahrq.gov/issue/care-delivery-within-community-mental-health-teams
Patient suicide is a sentinel event. This report examines a suicide incident that identified problems…
-
psnet.ahrq.gov/node/74846/psn-pdf
February 16, 2022 - Weight-based Medication Errors in Children.
February 16, 2022
Farnborough, UK: Healthcare Safety Investigation Branch; February 2022.
https://psnet.ahrq.gov/issue/weight-based-medication-errors-children
Weight-calculation errors can result in pediatric patient harm as they affect medication prescribing,
dispensing…
-
psnet.ahrq.gov/node/838196/psn-pdf
July 01, 2019 - The impact of racism on child and adolescent health.
July 1, 2019
Trent M, Dooley DG, Dougé J, et al. The impact of racism on child and adolescent health. Pediatrics.
2019;144(2):e20191765. doi:10.1542/peds.2019-1765.
https://psnet.ahrq.gov/issue/impact-racism-child-and-adolescent-health
Children and adolescents a…
-
psnet.ahrq.gov/node/46468/psn-pdf
December 13, 2017 - The effect of opioid prescribing guidelines on
prescriptions by emergency physicians in Ohio.
December 13, 2017
Weiner SG, Baker O, Poon SJ, et al. The Effect of Opioid Prescribing Guidelines on Prescriptions by
Emergency Physicians in Ohio. Ann Emerg Med. 2017;70(6):799-808.e1.
doi:10.1016/j.annemergmed.2017.03.0…
-
psnet.ahrq.gov/node/73475/psn-pdf
July 07, 2021 - Opioids in the United Kingdom: safety and surveillance
during COVID-19.
July 7, 2021
Osborne V. Opioids in the United Kingdom: safety and surveillance during COVID-19. Curr Opin
Psychiatry. 2021;34(4):357-362. doi:10.1097/yco.0000000000000719.
https://psnet.ahrq.gov/issue/opioids-united-kingdom-safety-and-surveill…
-
psnet.ahrq.gov/node/50915/psn-pdf
February 19, 2020 - Malpractice liability and health care quality: a review
February 19, 2020
Mello MM, Frakes MD, Blumenkranz E, et al. Malpractice liability and health care quality: A review . JAMA.
2020;323(4):352-366. doi:10.1001/jama.2019.21411.
https://psnet.ahrq.gov/issue/malpractice-liability-and-health-care-quality-review
Th…
-
psnet.ahrq.gov/node/847060/psn-pdf
January 01, 2001 - The Emperor’s New Clothes: Or Whatever Happened To
“Human Error”?
January 1, 2001
Hollnagel E, Amalberti R. Chapter In: Dekker SWA, ed. Proceedings of the 4th International
Workshop on Human Error, Safety and Systems Development. Linköping Sweden: Linköping University;
2001.
https://psnet.ahrq.gov/issu…
-
psnet.ahrq.gov/node/60897/psn-pdf
January 01, 2022 - Association between surgeon technical skills and patient
outcomes.
September 9, 2020
Stulberg JJ, Huang R, Kreutzer L, et al. Association Between Surgeon Technical Skills and Patient
Outcomes. JAMA Surg. 2022;157(3):219-220. doi:10.1001/jamasurg.2020.3007.
https://psnet.ahrq.gov/issue/association-between-surgeon-t…
-
psnet.ahrq.gov/node/45619/psn-pdf
August 16, 2017 - Checking the lists: a systematic review of electronic
checklist use in health care.
August 16, 2017
Kramer HS, Drews FA. Checking the lists: A systematic review of electronic checklist use in health care. J
Biomed Inform. 2017;71S:S6-S12. doi:10.1016/j.jbi.2016.09.006.
https://psnet.ahrq.gov/issue/checking-lists-s…
-
psnet.ahrq.gov/node/837605/psn-pdf
June 29, 2022 - Under the Skin. The Hidden Toll of Racism on American
Lives and on the Health of our Nation.
June 29, 2022
Villarosa L. New York, NT: Doubleday: 2022. ISBN 9780385544887.
https://psnet.ahrq.gov/issue/under-skin-hidden-toll-racism-american-lives-and-health-our-nation
Health inequities are receiving increased …
-
psnet.ahrq.gov/node/843318/psn-pdf
February 01, 2023 - Bending the patient safety curve: how much can AI help?
February 1, 2023
Classen DC, Longhurst CA, Thomas EJ. Bending the patient safety curve: how much can AI help? NPJ
Digit Med. 2023;6(1):2. doi:10.1038/s41746-022-00731-5.
https://psnet.ahrq.gov/issue/bending-patient-safety-curve-how-much-can-ai-help
Artificial…
-
psnet.ahrq.gov/node/60604/psn-pdf
June 17, 2020 - The limits of current A.I. in health care: patient safety
policing in hospitals.
June 17, 2020
Furrow BR. NE Univ Law Rev. 2020;12(1):1-55.
https://psnet.ahrq.gov/issue/limits-current-ai-health-care-patient-safety-policing-hospitals
Artificial intelligence (AI) has the potential to improve the use of big data to e…
-
psnet.ahrq.gov/node/38177/psn-pdf
March 02, 2011 - Violations of behavioral practices revealed in closed
claims reviews.
March 2, 2011
Griffen FD, Stephens LS, Alexander JB, et al. Violations of behavioral practices revealed in closed claims
reviews. Ann Surg. 2008;248(3):468-474. doi:10.1097/sla.0b013e318185e196.
https://psnet.ahrq.gov/issue/violations-behavioral…
-
psnet.ahrq.gov/node/44445/psn-pdf
September 16, 2015 - Understanding nurses' and physicians' fear of
repercussions for reporting errors: clinician
characteristics, organization demographics, or leadership
factors?
September 16, 2015
Castel ES, Ginsburg LR, Zaheer S, et al. Understanding nurses' and physicians' fear of repercussions for
reporting errors: clinician cha…
-
psnet.ahrq.gov/node/47774/psn-pdf
April 08, 2019 - Association of emotional intelligence with malpractice
claims: a review.
April 8, 2019
Shouhed D, Beni C, Manguso N, et al. Association of Emotional Intelligence With Malpractice Claims: A
Review. JAMA Surg. 2019;154(3):250-256. doi:10.1001/jamasurg.2018.5065.
https://psnet.ahrq.gov/issue/association-emotional-int…
-
psnet.ahrq.gov/node/43648/psn-pdf
November 21, 2016 - Patient- and family-centered care: error disclosure and
investigation.
November 21, 2016
Connor M; Wayman KI; Garcia C; Fischer PR; Consortium for Maximizing Family-Centered Care.
https://psnet.ahrq.gov/issue/patient-and-family-centered-care-error-disclosure-and-investigation
Patients are increasingly encouraged t…
-
psnet.ahrq.gov/node/838191/psn-pdf
September 28, 2022 - Improved Diagnostic Accuracy Through Probability-
Based Diagnosis.
September 28, 2022
Rockville, MD: Agency for Healthcare Research and Quality; September 2022. AHRQ Publication No. 22-
0026-3-EF.
https://psnet.ahrq.gov/issue/improved-diagnostic-accuracy-through-probability-based-diagnosis
Correct consideration o…