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psnet.ahrq.gov/node/74130/psn-pdf
December 01, 2021 - Malpractice cases in breast surgery: an assessment of
litigation involving surgeons.
December 1, 2021
Fan B, Pardo J, Yu-Moe CW, et al. Malpractice cases in breast surgery: an assessment of litigation
involving surgeons. Ann Surg Oncol. 2021;28(13):8109-8115. doi:10.1245/s10434-021-10236-2.
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psnet.ahrq.gov/node/47912/psn-pdf
April 24, 2019 - A systematic literature review and narrative synthesis on
the risks of medical discharge letters for patients' safety.
April 24, 2019
Schwarz CM, Hoffmann M, Schwarz P, et al. A systematic literature review and narrative synthesis on the
risks of medical discharge letters for patients' safety. BMC Health Serv Res. …
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October 16, 2024 - Beyond error: a qualitative study of human factors in
serious adverse events.
October 16, 2024
Mujuru C, Peisah C. Beyond error: a qualitative study of human factors in serious adverse events. J
Healthc Risk Manag. 2024;44(2):7-13. doi:10.1002/jhrm.21583.
https://psnet.ahrq.gov/issue/beyond-error-qualitative-study…
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psnet.ahrq.gov/node/47438/psn-pdf
June 02, 2019 - Developing an intervention to reduce harm in hospitalized
patients: patients and families in research.
June 2, 2019
Schenk EC, Bryant RA, Van Son CR, et al. Developing an Intervention to Reduce Harm in Hospitalized
Patients: Patients and Families in Research. J Nurs Care Qual. 2019;34(3):273-278.
doi:10.1097/NCQ.0…
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psnet.ahrq.gov/node/47879/psn-pdf
June 05, 2019 - The attitudes of nursing students and clinical instructors
towards reporting irregular incidents in the medical clinic.
June 5, 2019
Halperin O, Bronshtein O. The attitudes of nursing students and clinical instructors towards reporting
irregular incidents in the medical clinic. Nurse Educ Pract. 2019;36:34-39. doi:…
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psnet.ahrq.gov/node/73888/psn-pdf
September 29, 2021 - Interventions to reduce medication dispensing,
administration, and monitoring errors in pediatric
professional healthcare settings: a systematic review.
September 29, 2021
Koeck JA, Young NJ, Kontny U, et al. Interventions to reduce medication dispensing, administration, and
monitoring errors in pediatric professi…
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psnet.ahrq.gov/node/37000/psn-pdf
September 15, 2011 - Unanticipated death after discharge home from the
emergency department.
September 15, 2011
Sklar DP, Crandall CS, Loeliger E, et al. Unanticipated Death After Discharge Home From the Emergency
Department. Ann Emerg Med. 2007;49(6). doi:10.1016/j.annemergmed.2006.11.018.
https://psnet.ahrq.gov/issue/unanticipated-d…
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March 28, 2011 - Active surveillance using electronic triggers to detect
adverse events in hospitalized patients.
March 28, 2011
Szekendi MK, Sullivan C, Bobb A, et al. Active surveillance using electronic triggers to detect adverse
events in hospitalized patients. Qual Saf Health Care. 2006;15(3):184-90.
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psnet.ahrq.gov/node/847049/psn-pdf
April 05, 2023 - Effects of racial bias in pulse oximetry on children and
how to address algorithmic bias in clinical medicine.
April 5, 2023
Gray KD, Subramaniam HL, Huang ES. Effects of racial bias in pulse oximetry on children and how to
address algorithmic bias in clinical medicine. JAMA Pediatr. 2023;177(5):459-460.
doi:10.10…
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December 08, 2021 - Pointing fingers: verbosity of patient safety narratives is
associated with attribution of blame.
December 8, 2021
Ackerman RS, Patel SY, Costache M, et al. Anesthesiology News. November 21, 2021.
https://psnet.ahrq.gov/issue/pointing-fingers-verbosity-patient-safety-narratives-associated-attribution-
bl…
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September 07, 2016 - Drug Shortages: Certain Factors Are Strongly Associated
With This Persistent Public Health Challenge.
September 7, 2016
Washington, DC: United States Government Accountability Office; July 7, 2016. Publication GAO-16-595.
https://psnet.ahrq.gov/issue/drug-shortages-certain-factors-are-strongly-associated-persistent…
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April 24, 2024 - Pay-for-performance and patient safety in acute care: a
systematic review.
April 24, 2024
Slawomirski L, Hensher M, Campbell JL, et al. Pay-for-performance and patient safety in acute care: a
systematic review. Health Policy. 2024;143:105051. doi:10.1016/j.healthpol.2024.105051.
https://psnet.ahrq.gov/issue/pay-pe…
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September 26, 2018 - The Psychiatry Morbidity and Mortality Incident Reporting
Tool increases psychiatrist participation in reporting
adverse events.
September 26, 2018
Kroll DS, Shellman AD, Gitlin DF. The Psychiatry Morbidity and Mortality Incident Reporting Tool Increases
Psychiatrist Participation in Reporting Adverse Events. J Pa…
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December 12, 2018 - Learning from tragedy: the Julia Berg story.
December 12, 2018
Graber ML, Berg D, Jerde W, et al. Learning from tragedy: the Julia Berg story. Diagnosis (Berl).
2018;5(4):257-266. doi:10.1515/dx-2018-0067.
https://psnet.ahrq.gov/issue/learning-tragedy-julia-berg-story
This commentary provides a clinical review of …
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August 10, 2022 - Do patient engagement IT functionalities influence patient
safety outcomes? A study of US hospitals.
August 10, 2022
Upadhyay S, Opoku-Agyeman W, Choi S, et al. Do patient engagement IT functionalities influence patient
safety outcomes? A study of US hospitals. J Public Health Manag Pract. 2022;28(5):505-512.
doi:…
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April 11, 2011 - Incidence, preventability and consequences of adverse
events in older people: results of a retrospective case-
note review.
April 11, 2011
Sari ABA, Cracknell A, Sheldon T. Incidence, preventability and consequences of adverse events in older
people: results of a retrospective case-note review. Age Ageing. 2008;37…
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September 07, 2016 - Measuring adverse events in hospitalized patients: an
administrative method for measuring harm.
September 7, 2016
Martin J, Benjamin EM, Craver C, et al. Measuring Adverse Events in Hospitalized Patients: An
Administrative Method for Measuring Harm. J Patient Saf. 2016;12(3):125-31.
doi:10.1097/PTS.000000000000007…
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June 24, 2020 - Design and implementation of the infection prevention
program into risk management: managing high level
disinfection and sterilization in the outpatient setting.
June 24, 2020
Sweet W, Snyder D, Raymond M. Design and implementation of the infection prevention program into risk
management: Managing high level disin…
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July 15, 2020 - The scientific literature on Coronaviruses, COVID-19 and
its associated safety-related research dimensions: a
scientometric analysis and scoping review.
July 15, 2020
Haghani M, Bliemer MCJ, Goerlandt F, et al. The scientific literature on Coronaviruses, COVID-19 and its
associated safety-related research dimensio…
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psnet.ahrq.gov/node/49666/psn-pdf
October 01, 2012 - CA-MRSA Skin Infections: An Ounce of Prevention is
Worth a Pound of Cure
October 1, 2012
Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet].
2012.
https://psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
Case Objectives
Identify risk f…