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psnet.ahrq.gov/node/49564/psn-pdf
July 01, 2008 - Dependence vs. Pain
July 1, 2008
Gordon AJ. Dependence vs. Pain . PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/dependence-vs-pain
Case Objectives
Define opioid dependence and opioid withdrawal syndrome.
Describe the treatment of opioid withdrawal syndrome including the use of the Clinical Opioid
Withdra…
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep
January 1, 2019
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
Case Objectives
List the patient safety events that are unique to in…
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - SPOTLIGHT CASE
Spotlight: Mistaken Attribution, Diagnostic Misstep
Citation Text:
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citat…
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psnet.ahrq.gov/node/45329/psn-pdf
April 24, 2018 - State legal restrictions and prescription-opioid use
among disabled adults.
April 24, 2018
Meara E, Horwitz JR, Powell W, et al. State Legal Restrictions and Prescription-Opioid Use among
Disabled Adults. N Engl J Med. 2016;375(1):44-53. doi:10.1056/NEJMsa1514387.
https://psnet.ahrq.gov/issue/state-legal-restricti…
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psnet.ahrq.gov/node/47603/psn-pdf
March 20, 2019 - Electronic patient identification for sample labeling
reduces wrong blood in tube errors.
March 20, 2019
Kaufman RM, Dinh A, Cohn CS, et al. Electronic patient identification for sample labeling reduces wrong
blood in tube errors. Transfusion (Paris). 2019;59(3):972-980. doi:10.1111/trf.15102.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/46616/psn-pdf
July 02, 2019 - Medication-related clinical decision support alert
overrides in inpatients.
July 2, 2019
Nanji KC, Seger DL, Slight SP, et al. Medication-related clinical decision support alert overrides in
inpatients. J Am Med Inform Assoc. 2018;25(5):476-481. doi:10.1093/jamia/ocx115.
https://psnet.ahrq.gov/issue/medication-rel…
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psnet.ahrq.gov/node/45681/psn-pdf
January 25, 2017 - Economic evaluation of quality improvement
interventions for bloodstream infections related to central
catheters: a systematic review.
January 25, 2017
Nuckols TK, Keeler E, Morton SC, et al. Economic Evaluation of Quality Improvement Interventions for
Bloodstream Infections Related to Central Catheters: A Systema…
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psnet.ahrq.gov/node/43037/psn-pdf
October 31, 2014 - Adverse Events in Skilled Nursing Facilities: National
Incidence Among Medicare Beneficiaries.
October 31, 2014
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector
General; February 2014. Report No. OEI-06-11-00370.
https://psnet.ahrq.gov/issue/adverse-events-skilled-nu…
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psnet.ahrq.gov/node/45065/psn-pdf
June 01, 2016 - Variation in quality of urgent health care provided during
commercial virtual visits.
June 1, 2016
Schoenfeld AJ, Davies JM, Marafino BJ, et al. Variation in Quality of Urgent Health Care Provided During
Commercial Virtual Visits. JAMA Intern Med. 2016;176(5):635-42. doi:10.1001/jamainternmed.2015.8248.
https://ps…
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psnet.ahrq.gov/node/43617/psn-pdf
September 24, 2016 - Do telephone call interruptions have an impact on
radiology resident diagnostic accuracy?
September 24, 2016
Balint BJ, Steenburg SD, Lin H, et al. Do telephone call interruptions have an impact on radiology resident
diagnostic accuracy? Acad Radiol. 2014;21(12):1623-8. doi:10.1016/j.acra.2014.08.001.
https://psne…
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psnet.ahrq.gov/node/45319/psn-pdf
September 01, 2018 - Special Issue: Progress at the Intersection of Patient
Safety and Medical Liability.
September 1, 2018
Ridgely MS, Greenberg MD, Clancy CM, eds. Health Serv Res. 2016;51(suppl 3):2395-2648.
https://psnet.ahrq.gov/issue/special-issue-progress-intersection-patient-safety-and-medical-liability
Medical liability refor…
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psnet.ahrq.gov/node/46203/psn-pdf
June 14, 2017 - Prescription errors related to the use of computerized
provider order-entry system for pediatric patients.
June 14, 2017
Alhanout K, Bun S-S, Retornaz K, et al. Prescription errors related to the use of computerized provider
order-entry system for pediatric patients. Int J Med Inform. 2017;103:15-19.
doi:10.1016/j…
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psnet.ahrq.gov/node/43074/psn-pdf
December 18, 2014 - Graded autonomy in medical education—managing
things that go bump in the night.
December 18, 2014
Halpern S, Detsky AS. Graded autonomy in medical education--managing things that go bump in the night.
N Engl J Med. 2014;370(12):1086-1089. doi:10.1056/NEJMp1315408.
https://psnet.ahrq.gov/issue/graded-autonomy-medic…
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psnet.ahrq.gov/node/37908/psn-pdf
June 10, 2010 - Incidence and characteristics of potential and actual
retained foreign object events in surgical patients.
June 10, 2010
Cima RR, Kollengode A, Garnatz J, et al. Incidence and characteristics of potential and actual retained
foreign object events in surgical patients. J Am Coll Surg. 2008;207(1):80-7.
doi:10.1016/…
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psnet.ahrq.gov/node/38983/psn-pdf
February 10, 2015 - Improving safety and eliminating redundant tests: cutting
costs in U.S. hospitals.
February 10, 2015
Jha AK, Chan DC, Ridgway AB, et al. Improving safety and eliminating redundant tests: cutting costs in
U.S. hospitals. Health Aff (Millwood). 2009;28(5):1475-1484. doi:10.1377/hlthaff.28.5.1475.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/46173/psn-pdf
August 20, 2018 - Advances in Patient Safety and Medical Liability.
August 20, 2018
Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality;
2017. AHRQ Publication No. 17-0017-EF.
https://psnet.ahrq.gov/issue/advances-patient-safety-and-medical-liability
This publication describes the re…
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psnet.ahrq.gov/node/39337/psn-pdf
May 07, 2014 - Clinical and economic outcomes attributable to health
care–associated sepsis and pneumonia.
May 7, 2014
Eber MR, Laxminarayan R, Perencevich E, et al. Clinical and economic outcomes attributable to health
care-associated sepsis and pneumonia. Arch Intern Med. 2010;170(4):347-53.
doi:10.1001/archinternmed.2009.509.…
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psnet.ahrq.gov/node/74230/psn-pdf
January 12, 2022 - Learning from diagnostic errors to improve patient safety
when GPs work in or alongside emergency departments:
incorporating realist methodology into patient safety
incident report analysis.
January 12, 2022
Cooper A, Carson-Stevens A, Cooke M, et al. Learning from diagnostic errors to improve patient safety
when…
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psnet.ahrq.gov/node/46612/psn-pdf
February 22, 2018 - Influencing organisational culture to improve hospital
performance in care of patients with acute myocardial
infarction: a mixed-methods intervention study.
February 22, 2018
Curry LA, Brault MA, Linnander EL, et al. Influencing organisational culture to improve hospital
performance in care of patients with acute …
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psnet.ahrq.gov/node/44993/psn-pdf
April 17, 2017 - Surgical patient safety outcomes in critical access
hospitals: how do they compare?
April 17, 2017
Natafgi N, Baloh J, Weigel P, et al. Surgical Patient Safety Outcomes in Critical Access Hospitals: How Do
They Compare? J Rural Health. 2016;33(2):117-126. doi:10.1111/jrh.12176.
https://psnet.ahrq.gov/issue/surgica…