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psnet.ahrq.gov/node/41947/psn-pdf
January 30, 2013 - Self-reported patient safety competence among new
graduates in medicine, nursing and pharmacy.
January 30, 2013
Ginsburg LR, Tregunno D, Norton PG. Self-reported patient safety competence among new graduates in
medicine, nursing and pharmacy. BMJ Qual Saf. 2013;22(2):147-54. doi:10.1136/bmjqs-2012-001308.
https://…
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psnet.ahrq.gov/node/47258/psn-pdf
January 09, 2019 - The effect of cognitive load and task complexity on
automation bias in electronic prescribing.
January 9, 2019
Lyell D, Magrabi F, Coiera E. The Effect of Cognitive Load and Task Complexity on Automation Bias in
Electronic Prescribing. Hum Factors. 2018;60(7):1008-1021. doi:10.1177/0018720818781224.
https://psnet.…
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psnet.ahrq.gov/node/44419/psn-pdf
September 02, 2015 - Lack of standardisation between specialties for human
factors content in postgraduate training: an analysis of
specialty curricula in the UK.
September 2, 2015
Greig PR, Higham H, Vaux E. Lack of standardisation between specialties for human factors content in
postgraduate training: an analysis of specialty curric…
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psnet.ahrq.gov/node/48094/psn-pdf
June 19, 2019 - New persistent opioid use after postoperative intensive
care in US veterans.
June 19, 2019
Karamchandani K, Pyati S, Bryan W, et al. New Persistent Opioid Use After Postoperative Intensive Care
in US Veterans. JAMA Surg. 2019;154(8):778-780. doi:10.1001/jamasurg.2019.0899.
https://psnet.ahrq.gov/issue/new-persiste…
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psnet.ahrq.gov/node/46707/psn-pdf
October 13, 2018 - Medication errors involving nursing students: a
systematic review.
October 13, 2018
Asensi-Vicente J, Jiménez-Ruiz I, Vizcaya-Moreno F. Medication Errors Involving Nursing Students: A
Systematic Review. Nurse Educ. 2018;43(5):E1-E5. doi:10.1097/NNE.0000000000000481.
https://psnet.ahrq.gov/issue/medication-errors-i…
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psnet.ahrq.gov/node/866114/psn-pdf
June 12, 2024 - Influence of external assessment on quality and safety in
surgery: a qualitative study of surgeons' perspectives.
June 12, 2024
Øyri SF, Wiig S, Tjomsland O. Influence of external assessment on quality and safety in surgery: a
qualitative study of surgeons’ perspectives. BMJ Open Qual. 2024;13(2):e002672. doi:10.11…
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psnet.ahrq.gov/node/866311/psn-pdf
January 01, 2025 - Systematic review of types of safety incidents and the
processes and systems used for safety incident reporting
in care homes.
July 17, 2024
Scott J, Sykes K, Waring J, et al. Systematic review of types of safety incidents and the processes and
systems used for safety incident reporting in care homes. J Adv Nurs. …
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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…
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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…
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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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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-…
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psnet.ahrq.gov/node/44490/psn-pdf
September 16, 2015 - Implementation of a custom alert to prevent medication-
timing errors associated with computerized prescriber
order entry.
September 16, 2015
Idemoto LM, Williams BL, Ching JM, et al. Implementation of a custom alert to prevent medication-timing
errors associated with computerized prescriber order entry. Am J Heal…
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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.…
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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…
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of
Previous Abdominal Operations
February 26, 2025
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous
Abdominal Operations. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
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psnet.ahrq.gov/node/45653/psn-pdf
January 25, 2017 - Opioid prescribing after surgical extraction of teeth in
Medicaid patients, 2000–2010.
January 25, 2017
Baker JA, Avorn J, Levin R, et al. Opioid Prescribing After Surgical Extraction of Teeth in Medicaid
Patients, 2000-2010. JAMA. 2016;315(15):1653-4. doi:10.1001/jama.2015.19058.
https://psnet.ahrq.gov/issue/opio…
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psnet.ahrq.gov/node/854641/psn-pdf
October 18, 2023 - Ranking of the Rate of State Medical Boards’ Serious
Disciplinary Actions, 2019-2021.
October 18, 2023
Wolfe SW, Oshel RE. Washington, DC: Public Citizen; August 16, 2023.
https://psnet.ahrq.gov/issue/ranking-rate-state-medical-boards-serious-disciplinary-actions-2019-2021
There are recognized systemic w…
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psnet.ahrq.gov/node/50448/psn-pdf
October 09, 2019 - Diagnostic errors reported in primary healthcare and
emergency departments: a retrospective and descriptive
cohort study of 4830 reported cases of preventable harm
in Sweden.
October 9, 2019
Fernholm R, Pukk Härenstam K, Wachtler C, et al. Diagnostic errors reported in primary healthcare and
emergency departments…
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psnet.ahrq.gov/node/34645/psn-pdf
December 23, 2008 - How do patients want physicians to handle mistakes? A
survey of internal medicine patients in an academic
setting.
December 23, 2008
Witman AB, Park DM, Hardin SB. How do patients want physicians to handle mistakes? A survey of
internal medicine patients in an academic setting. Arch Intern Med. 1996;156(22):2565-9…
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psnet.ahrq.gov/node/50589/psn-pdf
October 30, 2019 - Missed serious neurologic conditions in emergency
department patients discharged with nonspecific
diagnoses of headache or back pain.
October 30, 2019
Dubosh NM, Edlow JA, Goto T, et al. Missed Serious Neurologic Conditions in Emergency Department
Patients Discharged With Nonspecific Diagnoses of Headache or Back …