-
psnet.ahrq.gov/node/42637/psn-pdf
December 29, 2014 - Approaches for improving continuity of care in
medication management: a systematic review.
December 29, 2014
Spinewine A, Claeys C, Foulon V, et al. Approaches for improving continuity of care in medication
management: a systematic review. Int J Qual Health Care. 2013;25(4):403-17. doi:10.1093/intqhc/mzt032.
https…
-
psnet.ahrq.gov/node/35193/psn-pdf
July 10, 2008 - Diagnostic error in internal medicine.
July 10, 2008
Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med.
2005;165(13):1493-1499.
https://psnet.ahrq.gov/issue/diagnostic-error-internal-medicine
This study identified 100 cases of diagnostic error in internal medicine and conducte…
-
psnet.ahrq.gov/node/40425/psn-pdf
August 02, 2012 - Incidence and impact of physician and nurse disruptive
behaviors in the emergency department.
August 2, 2012
Rosenstein AH, Naylor B. Incidence and impact of physician and nurse disruptive behaviors in the
emergency department. J Emerg Med. 2012;43(1):139-48. doi:10.1016/j.jemermed.2011.01.019.
https://psnet.ahrq.…
-
psnet.ahrq.gov/node/34636/psn-pdf
June 14, 2011 - The wrong patient.
June 14, 2011
Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136(11):826-833.
https://psnet.ahrq.gov/issue/wrong-patient
This case study describes the events of a patient who underwent an unintended invasive cardiac
electrophysiology study. While reviewing the details of the case…
-
psnet.ahrq.gov/node/49579/psn-pdf
March 21, 2009 - These "ring downs" are necessarily brief, do not include identifying information (beyond patient
age
-
psnet.ahrq.gov/node/35228/psn-pdf
March 04, 2011 - Best practices for safe handling of products containing
concentrated potassium.
March 4, 2011
Tubman M, Majumdar SR, Lee D, et al. Best practices for safe handling of products containing
concentrated potassium. BMJ. 2005;331(7511):274-7.
https://psnet.ahrq.gov/issue/best-practices-safe-handling-products-containing…
-
psnet.ahrq.gov/node/43846/psn-pdf
January 21, 2015 - Quantifying and monitoring overdiagnosis in cancer
screening: a systematic review of methods.
January 21, 2015
Carter JL, Coletti RJ, Harris RP. Quantifying and monitoring overdiagnosis in cancer screening: a
systematic review of methods. BMJ. 2015;350:g7773. doi:10.1136/bmj.g7773.
https://psnet.ahrq.gov/issue/qua…
-
psnet.ahrq.gov/node/39169/psn-pdf
December 09, 2009 - Exploring the concept of medication discrepancy within
the context of patient safety to improve population health.
December 9, 2009
Murphy CR, Corbett CL, Setter SM, et al. Exploring the concept of medication discrepancy within the
context of patient safety to improve population health. ANS Adv Nurs Sci. 2009;32(4)…
-
psnet.ahrq.gov/node/34117/psn-pdf
December 23, 2016 - Sentinel Event.
December 23, 2016
The Joint Commission.
https://psnet.ahrq.gov/issue/sentinel-event
Since 1998, The Joint Commission has issued sentinel event alerts in response to unexpected incidents
involving death or serious physical or psychological injury (or risk thereof). These events are identified as
se…
-
psnet.ahrq.gov/node/42089/psn-pdf
March 06, 2013 - Organizational culture: an important context for
addressing and improving hospital to community patient
discharge.
March 6, 2013
Hesselink G, Vernooij-Dassen M, Pijnenborg L, et al. Organizational culture: an important context for
addressing and improving hospital to community patient discharge. Med Care. 2013;51(…
-
psnet.ahrq.gov/node/44284/psn-pdf
September 09, 2015 - Operating room to intensive care unit handoffs and the
risks of patient harm.
September 9, 2015
McElroy LM, Collins KM, Koller FL, et al. Operating room to intensive care unit handoffs and the risks of
patient harm. Surgery. 2015;158(3):588-594. doi:10.1016/j.surg.2015.03.061.
https://psnet.ahrq.gov/issue/operatin…
-
psnet.ahrq.gov/node/39333/psn-pdf
May 04, 2010 - Explaining ethnic disparities in patient safety: a
qualitative analysis.
May 4, 2010
Suurmond J, Uiters E, de Bruijne M, et al. Explaining ethnic disparities in patient safety: a qualitative
analysis. Am J Public Health. 2010;100 Suppl 1:S113-7. doi:10.2105/AJPH.2009.167064.
https://psnet.ahrq.gov/issue/explaining…
-
psnet.ahrq.gov/node/60889/psn-pdf
January 01, 2021 - Expert consensus on currently accepted measures of
harm.
September 9, 2020
Logan MS, Myers LC, Salmasian H, et al. Expert consensus on currently accepted measures of harm. J
Patient Saf. 2021;17(8):e1726-e1731. doi:10.1097/pts.0000000000000754.
https://psnet.ahrq.gov/issue/expert-consensus-currently-accepted-measu…
-
psnet.ahrq.gov/node/836864/psn-pdf
April 06, 2022 - Improving the specificity of drug-drug interaction alerts:
can it be done?
April 6, 2022
Reese T, Wright A, Liu S, et al. Improving the specificity of drug-drug interaction alerts: Can it be done? Am
J Health Syst Pharm. 2022;79(13):1086-1095. doi:10.1093/ajhp/zxac045.
https://psnet.ahrq.gov/issue/improving-specif…
-
psnet.ahrq.gov/node/46767/psn-pdf
January 17, 2018 - What this computer needs is a physician: humanism and
artificial intelligence.
January 17, 2018
Verghese A, Shah NH, Harrington RA. What This Computer Needs Is a Physician: Humanism and Artificial
Intelligence. JAMA. 2018;319(1):19-20. doi:10.1001/jama.2017.19198.
https://psnet.ahrq.gov/issue/what-computer-needs-p…
-
psnet.ahrq.gov/node/42562/psn-pdf
June 09, 2015 - Sustaining quality improvement and patient safety
training in graduate medical education: lessons from
social theory.
June 9, 2015
Wong BM, Kuper A, Hollenberg E, et al. Sustaining quality improvement and patient safety training in
graduate medical education: lessons from social theory. Acad Med. 2013;88(8):1149-5…
-
psnet.ahrq.gov/node/45916/psn-pdf
March 08, 2017 - Feeling unsafe in the healthcare setting: patients'
perspectives.
March 8, 2017
Kenward L, Whiffin C, Spalek B. Feeling unsafe in the healthcare setting: patients' perspectives. Br J Nurs.
2017;26(3):143-149. doi:10.12968/bjon.2017.26.3.143.
https://psnet.ahrq.gov/issue/feeling-unsafe-healthcare-setting-patients-p…
-
psnet.ahrq.gov/node/73447/psn-pdf
June 30, 2021 - Errors in adult trauma resuscitation: a systematic review.
June 30, 2021
Nikouline A, Quirion A, Jung JJ, et al. Errors in adult trauma resuscitation: a systematic review. CJEM.
2021;23:537–546. doi:10.1007/s43678-021-00118-7.
https://psnet.ahrq.gov/issue/errors-adult-trauma-resuscitation-systematic-review
Trauma …
-
psnet.ahrq.gov/node/36691/psn-pdf
January 18, 2011 - The burden and risk factors for adverse drug events in
older patients--a prospective cross-sectional study.
January 18, 2011
Tipping B, Kalula S, Badri M. The burden and risk factors for adverse drug events in older patients--a
prospective cross-sectional study. S Afr Med J. 2006;96(12):1255-1259.
https://psnet.ah…
-
psnet.ahrq.gov/node/47826/psn-pdf
March 27, 2019 - Office-based surgery and patient outcomes.
March 27, 2019
Young S, Shapiro FE, Urman RD. Office-based surgery and patient outcomes. Curr Opin Anaesthesiol.
2018;31(6):707-712. doi:10.1097/ACO.0000000000000655.
https://psnet.ahrq.gov/issue/office-based-surgery-and-patient-outcomes
Office-based surgery is increasing…