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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42405/psn-pdf
    July 10, 2013 - The role of patient involvement in the diagnostic process in internal medicine: a cognitive approach. July 10, 2013 Lucchiari C, Pravettoni G. The role of patient involvement in the diagnostic process in internal medicine: a cognitive approach. Eur J Intern Med. 2013;24(5):411-5. doi:10.1016/j.ejim.2013.01.022. ht…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61124/psn-pdf
    November 11, 2020 - Using Twitter to assess patient takes on patient experience. November 11, 2020 Heath S. Patient Engagement HIT. October 29, 2020. https://psnet.ahrq.gov/issue/using-twitter-assess-patient-takes-patient-experience Twitter is evolving as a useful data source for patient safety. This news story discusses an examinati…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73896/psn-pdf
    September 29, 2021 - Policies to promote shared responsibility for safer electronic health records. September 29, 2021 Sittig DF, Singh H. Policies to promote shared responsibility for safer electronic health records. JAMA. 2021;326(15):1477-1478. doi:10.1001/jama.2021.13945. https://psnet.ahrq.gov/issue/policies-promote-shared-respon…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44358/psn-pdf
    September 24, 2016 - Interruptions and medication administration in critical care. September 24, 2016 Bower R, Jackson C, Manning JC. Interruptions and medication administration in critical care. Nurs Crit Care. 2015;20(4):183-95. doi:10.1111/nicc.12185. https://psnet.ahrq.gov/issue/interruptions-and-medication-administration-critical…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866445/psn-pdf
    August 07, 2024 - Diagnosis in the Era of Digital Health and Artificial Intelligence: A Workshop. August 7, 2024 Diagnosis in the Era of Digital Health and Artificial Intelligence: A Workshop. https://psnet.ahrq.gov/issue/diagnosis-era-digital-health-and-artificial-intelligence-workshop Digital health is emerging as a primary techn…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72686/psn-pdf
    January 27, 2021 - The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making. January 27, 2021 Croskerry P. New York, NY: Oxford University Press; 2020. ISBN: 9780190088743.  https://psnet.ahrq.gov/issue/cognitive-autopsy-root-cause-analysis-medical-decision-making Diagnostic error reduction methods are evolv…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43887/psn-pdf
    April 08, 2018 - Types of diagnostic errors in neurological emergencies in the emergency department. April 8, 2018 Dubosh NM, Edlow JA, Lefton M, et al. Types of diagnostic errors in neurological emergencies in the emergency department. Diagnosis (Berl). 2015;2(1):21-28. doi:10.1515/dx-2014-0040. https://psnet.ahrq.gov/issue/types…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854264/psn-pdf
    October 04, 2023 - Patient death tied to lack of proper escalation process for barcode scanning failures. October 4, 2023 ISMP Medication Safety Alert! Acute Care edition. 2023;28(19):1-3. https://psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures Lack of experience with distinct process…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47779/psn-pdf
    June 12, 2019 - Medication accuracy in electronic health records for microbial keratitis. June 12, 2019 Ashfaq HA, Lester CA, Ballouz D, et al. Medication Accuracy in Electronic Health Records for Microbial Keratitis. JAMA Ophthalmal. 2019;137(8):929-931. doi:10.1001/jamaophthalmol.2019.1444. https://psnet.ahrq.gov/issue/medicati…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837346/psn-pdf
    June 08, 2022 - Decontamination of Surgical Instruments. June 8, 2022 Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022. https://psnet.ahrq.gov/issue/decontamination-surgical-instruments Surgical equipment sterilization can be hampered by equipment design, production pressures, process complexity and policy mi…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865597/psn-pdf
    April 17, 2024 - Discharge from Mental Health Care: Making it Safe and Patient-centred. April 17, 2024 Manchester, UK: Parliamentary and Health Service Ombudsman; March 2024. https://psnet.ahrq.gov/issue/discharge-mental-health-care-making-it-safe-and-patient-centred The provision of safe mental health care is receiving increased …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43084/psn-pdf
    May 19, 2014 - How can the criminal law support the provision of quality in healthcare? May 19, 2014 Yeung K, Horder J. How can the criminal law support the provision of quality in healthcare? BMJ Qual Saf. 2014;23(6):519-24. doi:10.1136/bmjqs-2013-002688. https://psnet.ahrq.gov/issue/how-can-criminal-law-support-provision-quali…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38952/psn-pdf
    September 16, 2009 - Has the pendulum swung too far?; The impact of missed abdominal injuries in the era of nonoperative management. September 16, 2009 Fairfax LM, Christmas B, Deaugustinis M, et al. Has the pendulum swung too far? The impact of missed abdominal injuries in the era of nonoperative management. Am Surg. 2009;75(7):558-6…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37575/psn-pdf
    September 08, 2010 - Systematic review: the evidence that publishing patient care performance data improves quality of care. September 8, 2010 Fung CH, Lim Y-W, Mattke S, et al. Systematic review: the evidence that publishing patient care performance data improves quality of care. Ann Intern Med. 2008;148(2):111-23. https://psnet.ahrq…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45039/psn-pdf
    September 27, 2016 - Deaths following prehospital safety incidents: an analysis of a national database. September 27, 2016 Yardley I, Donaldson LJ. Deaths following prehospital safety incidents: an analysis of a national database. Emerg Med J. 2016;33(10):716-721. doi:10.1136/emermed-2015-204724. https://psnet.ahrq.gov/issue/deaths-fo…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866935/psn-pdf
    October 09, 2024 - The Economics of Diagnostic Safety. October 9, 2024 de Bienassis K, Slawomirski L, Kelly D, et al. The Economics Of Diagnostic Safety. Paris, France: OECD Publishing; 2023. https://psnet.ahrq.gov/issue/economics-diagnostic-safety Ineffective diagnostic processes are common, wasteful, and harmful. This analysis exa…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42582/psn-pdf
    September 18, 2013 - When diagnostic testing leads to harm: a new outcomes- based approach for laboratory medicine. September 18, 2013 Epner PL, Gans JE, Graber ML. When diagnostic testing leads to harm: a new outcomes-based approach for laboratory medicine. BMJ Qual Saf. 2013;22 Suppl 2:ii6-ii10. doi:10.1136/bmjqs-2012-001621. https:…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35175/psn-pdf
    June 23, 2009 - Overnight and postcall errors in medication orders. June 23, 2009 Hendey GW, Barth BE, Soliz T. Overnight and postcall errors in medication orders. Acad Emerg Med. 2005;12(7):629-34. https://psnet.ahrq.gov/issue/overnight-and-postcall-errors-medication-orders This study examined the incidence of prescribing errors…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38061/psn-pdf
    November 08, 2008 - Medication errors in pediatric inpatients: prevalence and results of a prevention program. November 8, 2008 Otero P, Leyton A, Mariani G, et al. Medication errors in pediatric inpatients: prevalence and results of a prevention program. Pediatrics. 2008;122(3):e737-43. doi:10.1542/peds.2008-0014. https://psnet.ahrq…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38889/psn-pdf
    April 01, 2010 - Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation. April 1, 2010 Peute LW, Aarts J, Bakker PJM, et al. Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation. Int J Med Inform. 2010;79(4):e58-70. doi:…
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