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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38727/psn-pdf
    November 25, 2009 - FMEA team performance in health care: a qualitative analysis of team member perceptions. November 25, 2009 Wetterneck TB, Hundt AS, Carayon P. FMEA Team Performance in Health Care. J Patient Saf. 2009;5(2). doi:10.1097/pts.0b013e3181a852be. https://psnet.ahrq.gov/issue/fmea-team-performance-health-care-qualitative…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44320/psn-pdf
    October 28, 2015 - Interventions for reducing medication errors in children in hospital. October 28, 2015 Maaskant JM, Vermeulen H, Apampa B, et al. Interventions for reducing medication errors in children in hospital. Cochrane Database Syst Rev. 2015;(3):CD006208. doi:10.1002/14651858.CD006208.pub3. https://psnet.ahrq.gov/issue/int…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43937/psn-pdf
    May 05, 2018 - Getting closer to the bull's eye: 2014–2015 Targeted Medication Safety Best Practices. May 5, 2018 ISMP Medication Safety Alert! Acute Care Edition. February 12, 2015;20:1-5. https://psnet.ahrq.gov/issue/getting-closer-bulls-eye-2014-2015-targeted-medication-safety-best-practices Benchmarks tracking a wide spectru…
  4. psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
    January 01, 2025 - Spotlight Spotlight Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations  1 Source and Credits This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Samantha Brown…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866105/psn-pdf
    June 12, 2024 - Collective intelligence increases diagnostic accuracy in a general practice setting. June 12, 2024 Blanchard MD, Herzog SM, Kämmer JE, et al. Collective intelligence increases diagnostic accuracy in a general practice setting. Med Decis Making. 2024;44(4):451-462. doi:10.1177/0272989x241241001. https://psnet.ahrq.…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74085/psn-pdf
    November 17, 2021 - Race, ethnicity, and 60-day outcomes after hospitalization with COVID-19. November 17, 2021 Robinson-Lane SG, Sutton NR, Chubb H, et al. Race, ethnicity, and 60-day outcomes after hospitalization with COVID-19. J Am Med Dir Assoc. 2021;22(11):2245-2250. doi:10.1016/j.jamda.2021.08.023. https://psnet.ahrq.gov/issue…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48053/psn-pdf
    July 17, 2019 - Review of medication errors that are new or likely to occur more frequently with electronic medication management systems. July 17, 2019 Van de Vreede M, McGrath A, de Clifford J. Review of medication errors that are new or likely to occur more frequently with electronic medication management systems. Aust Health …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74273/psn-pdf
    January 19, 2022 - Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints. January 19, 2022 Washington, DC: United States Government Accountability Office; November 30, 2021. Publication GAO- 22-105142. https://psnet.ahrq.gov/issue/community-living-centers-va-needs-strengthen-its-approach-ad…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60813/psn-pdf
    January 01, 2021 - Medication-related interventions delivered both in hospital and following discharge: a systematic review and meta-analysis. August 19, 2020 Daliri S, Boujarfi S, el Mokaddam A, et al. Medication-related interventions delivered both in hospital and following discharge: a systematic review and meta-analysis. BMJ Qua…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47964/psn-pdf
    May 15, 2019 - Deaths among opioid users: impact of potential inappropriate prescribing practices. May 15, 2019 Jayawardhana J, Abraham AJ, Perri M. Deaths among opioid users: impact of potential inappropriate prescribing practices. Am J Manag Care. 2019;25(4):e98-e103. https://psnet.ahrq.gov/issue/deaths-among-opioid-users-impa…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852282/psn-pdf
    August 09, 2023 - Implementation of medication reconciliation in outpatient cancer care. August 9, 2023 Powis M, Dara C, Macedo A, et al. Implementation of medication reconciliation in outpatient cancer care. BMJ Open Quality. 2023;12(2):e002211. doi:10.1136/bmjoq-2022-002211. https://psnet.ahrq.gov/issue/implementation-medication-…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43907/psn-pdf
    April 27, 2015 - Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality. April 27, 2015 Etzioni DA, Wasif N, Dueck AC, et al. Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality. JAMA. 2015;313…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45940/psn-pdf
    October 31, 2017 - Crossing the communication chasm: challenges and opportunities in transitions of care from the hospital to the primary care clinic. October 31, 2017 Rattray NA, Sico JJ, Cox LAM, et al. Crossing the Communication Chasm: Challenges and Opportunities in Transitions of Care from the Hospital to the Primary Care Clini…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866323/psn-pdf
    July 17, 2024 - AHRQ-Funded Patient Safety Project Highlights: Improving Patient Safety by Enhancing Care Coordination. July 17, 2024 Rockville, MD: Agency for Healthcare Research and Quality; June 2024. AHRQ Pub. No. 24-0017-2-EF. https://psnet.ahrq.gov/issue/ahrq-funded-patient-safety-project-highlights-improving-patient-safety…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46141/psn-pdf
    May 17, 2017 - Ethical dilemma in missed melanoma: what to tell the patient and other providers. May 17, 2017 Vangipuram R, Horner ME, Menter A. Ethical dilemma in missed melanoma: What to tell the patient and other providers. J Am Acad Dermatol. 2017;76(2):365-367. doi:10.1016/j.jaad.2016.08.030. https://psnet.ahrq.gov/issue/et…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36088/psn-pdf
    September 28, 2010 - Impact and implications of disruptive behavior in the perioperative arena. September 28, 2010 Rosenstein AH, O'Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J Am Coll Surg. 2006;203(1):96-105. https://psnet.ahrq.gov/issue/impact-and-implications-disruptive-behavior-perioperat…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41996/psn-pdf
    July 03, 2014 - Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. July 3, 2014 Antiel RM, Reed DA, Van Arendonk K, et al. Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. JAMA …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46702/psn-pdf
    April 16, 2018 - Characteristics of medical liability claims against dermatologists from 1991 through 2015. April 16, 2018 Kornmehl H, Singh S, Adler BL, et al. Characteristics of Medical Liability Claims Against Dermatologists From 1991 Through 2015. JAMA Dermatol. 2018;154(2):160-166. doi:10.1001/jamadermatol.2017.3713. https://…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43805/psn-pdf
    February 11, 2015 - Understanding the nature of medication errors in an ICU with a computerized physician order entry system. February 11, 2015 Cho IS, Park H, Choi YJ, et al. Understanding the nature of medication errors in an ICU with a computerized physician order entry system. PLoS One. 2014;9(12):e114243. doi:10.1371/journal.pon…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44484/psn-pdf
    May 04, 2016 - Failure mode and effects analysis: a comparison of two common risk prioritisation methods. May 4, 2016 McElroy LM, Khorzad R, Nannicelli AP, et al. Failure mode and effects analysis: a comparison of two common risk prioritisation methods. BMJ Qual Saf. 2016;25(5):329-336. doi:10.1136/bmjqs-2015-004130. https://psn…

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