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psnet.ahrq.gov/node/46951/psn-pdf
June 26, 2018 - Emergency department boarding and adverse
hospitalization outcomes among patients admitted to a
general medical service.
June 26, 2018
Lord K, Parwani V, Ulrich A, et al. Emergency department boarding and adverse hospitalization outcomes
among patients admitted to a general medical service. Am J Emerg Med. 2018;36…
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psnet.ahrq.gov/node/45917/psn-pdf
March 29, 2017 - Improving our understanding of multi-tasking in
healthcare: drawing together the cognitive psychology
and healthcare literature.
March 29, 2017
Douglas HE, Raban MZ, Walter SR, et al. Improving our understanding of multi-tasking in healthcare:
Drawing together the cognitive psychology and healthcare literature. Ap…
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psnet.ahrq.gov/node/74056/psn-pdf
January 01, 2022 - Critical care simulation education program during the
COVID-19 pandemic.
November 10, 2021
Leibner ES, Baron EL, Shah RS, et al. Critical care simulation education program during the COVID-19
pandemic. J Patient Saf. 2022;18(4):e810-e815. doi:10.1097/pts.0000000000000928.
https://psnet.ahrq.gov/issue/critical-care…
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psnet.ahrq.gov/node/50620/psn-pdf
November 06, 2019 - Comparing rates of adverse events and medical errors on
inpatient psychiatric units at Veterans Health
Administration and community-based general hospitals.
November 6, 2019
Cullen SW, Xie M, Vermeulen JM, et al. Comparing Rates of Adverse Events and Medical Errors on
Inpatient Psychiatric Units at Veterans Health…
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psnet.ahrq.gov/node/845073/psn-pdf
February 22, 2023 - Nursing student errors and near misses: three years of
data.
February 22, 2023
Silvestre JH, Spector ND. Nursing student errors and near misses: three years of data. J Nurs Educ.
2023;62(1):12-19. doi:10.3928/01484834-20221109-05.
https://psnet.ahrq.gov/issue/nursing-student-errors-and-near-misses-three-years-data…
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psnet.ahrq.gov/node/47359/psn-pdf
October 10, 2018 - Is there evidence of a July effect among patients
undergoing hysterectomy surgery?
October 10, 2018
Varma S, Mehta A, Hutfless S, et al. Is there evidence of a July effect among patients undergoing
hysterectomy surgery? Am J Obstet Gynecol. 2018;219(2):176.e1-176.e9. doi:10.1016/j.ajog.2018.05.033.
https://psnet.a…
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psnet.ahrq.gov/node/859341/psn-pdf
January 01, 2024 - Disparities in patient safety voluntary event reporting: a
scoping review.
December 20, 2023
Hoops K, Pittman E, Stockwell DC. Disparities in patient safety voluntary event reporting: a scoping review.
Jt Comm J Qual Patient Saf. 2024;50(1):41-48. doi:10.1016/j.jcjq.2023.10.009.
https://psnet.ahrq.gov/issue/dispar…
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psnet.ahrq.gov/node/46891/psn-pdf
December 21, 2018 - Day of discharge does not impact hospital readmission
after major cardiac surgery.
December 21, 2018
Sanaiha Y, Ou R, Ramos G, et al. Day of Discharge Does Not Impact Hospital Readmission After Major
Cardiac Surgery. Ann Thorac Surg. 2018;106(6):1767-1773. doi:10.1016/j.athoracsur.2018.07.031.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/45617/psn-pdf
November 30, 2016 - Walking a tightrope: balancing the risk of diagnostic error
in inpatient pediatrics.
November 30, 2016
Berkwitt A, Osborn R, Grossman M. Walking a Tightrope: Balancing the Risk of Diagnostic Error in
Inpatient Pediatrics. Hosp Pediatr. 2016;6(9):566-8. doi:10.1542/hpeds.2016-0043.
https://psnet.ahrq.gov/issue/walk…
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psnet.ahrq.gov/web-mm/medication-overdose
September 01, 2011 - Medication Overdose
Citation Text:
Kaushal R. Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/web-mm/which-end-which
February 09, 2011 - Which End Is Which?
Citation Text:
Campbell AR. Which End Is Which?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/node/841493/psn-pdf
December 14, 2022 - Telehealth and Patient Safety.
December 14, 2022
O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/telehealth-and-patient-safety
Background
In recent years, telehealth, or the delivery of healthcare over a distance using telecommunications
techno…
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/node/34735/psn-pdf
June 16, 2014 - An Organisation with a Memory: Report of an Expert
Group on Learning from Adverse Events in the NHS
Chaired by the Chief Medical Officer.
June 16, 2014
Donaldson L. London, UK: The Stationery Office, 2000.
https://psnet.ahrq.gov/issue/organisation-memory-report-expert-group-learning-adverse-events-nhs-
chaired-ch…
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psnet.ahrq.gov/node/867691/psn-pdf
March 05, 2025 - Surgeon perception and attitude towards the moral
imperative of institutionally addressing second-victim
syndrome in surgery.
March 5, 2025
Hsiao L-H, Kopar PK. Surgeon perception and attitude towards the moral imperative of institutionally
addressing second-victim syndrome in surgery. J Am Coll Surg. 2025;240(2):…
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psnet.ahrq.gov/node/837859/psn-pdf
August 17, 2022 - The barriers and enhancers to trust in a just culture in
hospital settings: a systematic review.
August 17, 2022
van Marum S, Verhoeven D, de Rooy D. The barriers and enhancers to trust in a just culture in hospital
settings: a systematic review. J Patient Saf. 2022;18(7):e1067-e1075. doi:10.1097/pts.00000000000010…
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psnet.ahrq.gov/node/852799/psn-pdf
June 11, 2019 - The Giving Voice to Mothers study: inequity and
mistreatment during pregnancy and childbirth in the
United States.
June 11, 2019
Vedam S, Stoll K, Taiwo TK, et al. The Giving Voice to Mothers study: inequity and mistreatment during
pregnancy and childbirth in the United States. Reprod Health. 2019;16(1):77. doi:10…
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psnet.ahrq.gov/node/47883/psn-pdf
May 29, 2019 - Patient Safety in Obstetrics and Gynecology.
May 29, 2019
Gluck PA, ed. Obstet Gynecol Clin North Am. 2019;46:H1-H8, 199-398.
https://psnet.ahrq.gov/issue/patient-safety-obstetrics-and-gynecology
Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. Articles in
this speci…
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psnet.ahrq.gov/node/36434/psn-pdf
February 18, 2011 - Protocol-based computer reminders, the quality of care
and the non-perfectability of man.
February 18, 2011
McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability of man. N
Engl J Med. 1976;295(24):1351-5.
https://psnet.ahrq.gov/issue/protocol-based-computer-reminders-qualit…
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psnet.ahrq.gov/node/43496/psn-pdf
November 01, 2016 - Designing and Delivering Whole-Person Transitional
Care: Hospital Guide to Reducing Medicaid
Readmissions.
November 1, 2016
Boutwell A, Bourgoin A , Maxwell J, et al. Rockville, MD: Agency for Healthcare Research and Quality;
September 2016. AHRQ Publication No. 16-0047-EF.
https://psnet.ahrq.gov/issue/designing-…