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psnet.ahrq.gov/node/43042/psn-pdf
December 18, 2014 - Introduction of surgical safety checklists in Ontario,
Canada.
December 18, 2014
Urbach DR, Govindarajan A, Saskin R, et al. Introduction of Surgical Safety Checklists in Ontario, Canada.
New Engl J Med. 2014;370(11):1029-1038. doi:10.1056/nejmsa1308261.
https://psnet.ahrq.gov/issue/introduction-surgical-safety-ch…
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psnet.ahrq.gov/node/45615/psn-pdf
October 26, 2016 - Mandatory provider review and pain clinic laws reduce
the amounts of opioids prescribed and overdose death
rates.
October 26, 2016
Dowell D, Zhang K, Noonan RK, et al. Mandatory Provider Review And Pain Clinic Laws Reduce The
Amounts Of Opioids Prescribed And Overdose Death Rates. Health Aff (Millwood). 2016;35(10…
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psnet.ahrq.gov/node/47082/psn-pdf
July 02, 2019 - Effect of systematic physician cross-checking on
reducing adverse events in the emergency department:
the CHARMED cluster randomized trial.
July 2, 2019
Freund Y, Goulet H, Leblanc J, et al. Effect of Systematic Physician Cross-checking on Reducing Adverse
Events in the Emergency Department: The CHARMED Cluster Ra…
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psnet.ahrq.gov/node/46405/psn-pdf
October 13, 2018 - Children's hospitals' solutions for patient safety
collaborative impact on hospital-acquired harm.
October 13, 2018
Lyren A, Brilli RJ, Zieker K, et al. Children's Hospitals' Solutions for Patient Safety Collaborative Impact on
Hospital-Acquired Harm. Pediatrics. 2017;140(3). doi:10.1542/peds.2016-3494.
https://ps…
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psnet.ahrq.gov/issue/preventing-accidents-and-injuries-mri-suite
July 18, 2024 - Press Release/Announcement
Preventing accidents and injuries in the MRI suite.
Citation Text:
Preventing accidents and injuries in the MRI suite. Sentinel Event Alert. 2008;38(38):1-3.
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Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/node/46307/psn-pdf
August 20, 2018 - Post-operative mortality, missed care and nurse staffing
in nine countries: a cross-sectional study.
August 20, 2018
Ball JE, Bruyneel L, Aiken LH, et al. Post-operative mortality, missed care and nurse staffing in nine
countries: A cross-sectional study. Int J Nurs Stud. 2018;78:10-15. doi:10.1016/j.ijnurstu.2017.…
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psnet.ahrq.gov/node/46959/psn-pdf
August 20, 2018 - Education outcomes from a duty-hour flexibility trial in
internal medicine.
August 20, 2018
Desai SV, Asch DA, Bellini LM, et al. Education Outcomes in a Duty-Hour Flexibility Trial in Internal
Medicine. New Engl J Med. 2018;378(16):1494-1508. doi:10.1056/nejmoa1800965.
https://psnet.ahrq.gov/issue/education-outco…
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psnet.ahrq.gov/node/47228/psn-pdf
August 09, 2018 - A road map for advancing the practice of respect in health
care: the results of an interdisciplinary modified Delphi
consensus study.
August 9, 2018
Sokol-Hessner L, Folcarelli P, Annas CL, et al. A Road Map for Advancing the Practice of Respect in
Health Care: The Results of an Interdisciplinary Modified Delphi C…
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psnet.ahrq.gov/node/33578/psn-pdf
September 15, 2024 - Human Factors Engineering
September 15, 2024
Human Factors Engineering. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/human-factors-engineering
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safe…
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psnet.ahrq.gov/node/46122/psn-pdf
January 01, 2021 - Leapfrog Hospital Safety Score, Magnet designation, and
healthcare-associated infections in United States
hospitals.
December 21, 2017
Pakyz AL, Wang H, Ozcan YA, et al. Leapfrog Hospital Safety Score, Magnet Designation, and Healthcare-
Associated Infections in United States Hospitals. J Patient Saf. 2021;17(6):4…
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psnet.ahrq.gov/node/45887/psn-pdf
August 15, 2018 - Association of changing hospital readmission rates with
mortality rates after hospital discharge.
August 15, 2018
Dharmarajan K, Wang Y, Lin Z, et al. Association of Changing Hospital Readmission Rates With Mortality
Rates After Hospital Discharge. JAMA. 2017;318(3):270-278. doi:10.1001/jama.2017.8444.
https://psn…
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psnet.ahrq.gov/node/44084/psn-pdf
November 03, 2015 - Can staff and patient perspectives on hospital safety
predict harm-free care? An analysis of staff and patient
survey data and routinely collected outcomes.
November 3, 2015
Lawton R, O'Hara JK, Sheard L, et al. Can staff and patient perspectives on hospital safety predict harm-
free care? An analysis of staff and…
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psnet.ahrq.gov/node/42685/psn-pdf
December 06, 2013 - Impact of contact isolation for multidrug-resistant
organisms on the occurrence of medical errors and
adverse events.
December 6, 2013
Zahar JR, Garrouste-Orgeas M, Vesin A, et al. Impact of contact isolation for multidrug-resistant organisms
on the occurrence of medical errors and adverse events. Intensive Care M…
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psnet.ahrq.gov/node/43953/psn-pdf
March 04, 2015 - Psychological safety and error reporting within Veterans
Health Administration hospitals.
March 4, 2015
Derickson R, Fishman J, Osatuke K, et al. Psychological safety and error reporting within Veterans Health
Administration hospitals. J Patient Saf. 2015;11(1):60-66. doi:10.1097/PTS.0000000000000082.
https://psne…
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psnet.ahrq.gov/issue/reports-hospital-and-asc-performance
October 02, 2024 - Book/Report
Reports on Hospital and ASC Performance.
Citation Text:
Reports On Hospital And Asc Performance. Washington DC: The Leapfrog Group; September 2024.
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Format:
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Dow…
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psnet.ahrq.gov/node/47008/psn-pdf
October 13, 2018 - Impact of a commercial order entry system on prescribing
errors amenable to computerised decision support in the
hospital setting: a prospective pre–post study.
October 13, 2018
Pontefract SK, Hodson J, Slee A, et al. Impact of a commercial order entry system on prescribing errors
amenable to computerised decision…
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psnet.ahrq.gov/node/43972/psn-pdf
November 03, 2015 - National hospital ratings systems share few common
scores and may generate confusion instead of clarity.
November 3, 2015
Austin M, Jha AK, Romano PS, et al. National hospital ratings systems share few common scores and may
generate confusion instead of clarity. Health Aff (Millwood). 2015;34(3):423-430.
doi:10.13…
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psnet.ahrq.gov/node/43570/psn-pdf
March 26, 2015 - Nurses' shift length and overtime working in 12 European
countries: the association with perceived quality of care
and patient safety.
March 26, 2015
Griffiths P, Dall'Ora C, Simon M, et al. Nurses' shift length and overtime working in 12 European countries:
the association with perceived quality of care and patie…
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psnet.ahrq.gov/node/49735/psn-pdf
June 01, 2015 - Anchoring Bias With Critical Implications
June 1, 2015
Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
Case Objectives
Appreciate that diagnostic errors are common in primary and ambulatory care.
Define premature clo…
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psnet.ahrq.gov/node/73336/psn-pdf
May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping
Healthcare Providers
May 26, 2021
Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
The Case
…