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psnet.ahrq.gov/node/41408/psn-pdf
October 19, 2012 - Patient notification for bloodborne pathogen testing due
to unsafe injection practices in the US health care
settings, 2001–2011.
October 19, 2012
Guh AY, Thompson ND, Schaefer MK, et al. Patient notification for bloodborne pathogen testing due to
unsafe injection practices in the US health care settings, 2001-201…
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psnet.ahrq.gov/node/40963/psn-pdf
November 30, 2011 - Association between Leapfrog safe practices score and
hospital mortality in major surgery.
November 30, 2011
Qian F, Lustik SJ, Diachun CA, et al. Association between Leapfrog safe practices score and hospital
mortality in major surgery. Med Care. 2011;49(12):1082-1088. doi:10.1097/MLR.0b013e318238f26b.
https://ps…
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psnet.ahrq.gov/node/43323/psn-pdf
January 07, 2015 - Unrealized potential and residual consequences of
electronic prescribing on pharmacy workflow in the
outpatient pharmacy.
January 7, 2015
Nanji KC, Rothschild JM, Boehne JJ, et al. Unrealized potential and residual consequences of electronic
prescribing on pharmacy workflow in the outpatient pharmacy. J Am Med Inf…
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psnet.ahrq.gov/node/60248/psn-pdf
April 22, 2020 - Circumstances involved in unsupervised solid dose
medication exposures among young children.
April 22, 2020
Agarwal M, Lovegrove MC, Geller RJ, et al. Circumstances involved in unsupervised solid dose medication
exposures among young children. J Pediatr. 2020;219. doi:10.1016/j.jpeds.2019.12.027.
https://psnet.ahr…
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psnet.ahrq.gov/node/42969/psn-pdf
October 31, 2014 - Reducing the burden of surgical harm: a systematic
review of the interventions used to reduce adverse events
in surgery.
October 31, 2014
Howell A-M, Panesar S, Burns EM, et al. Reducing the burden of surgical harm: a systematic review of the
interventions used to reduce adverse events in surgery. Ann Surg. 2014;2…
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psnet.ahrq.gov/node/74050/psn-pdf
November 10, 2021 - Health disparities: impact of health disparities and
treatment decision-making biases on cancer adverse
effects among black cancer survivors.
November 10, 2021
Vo J, Gillman A, Mitchell K, et al. Health disparities: impact of health disparities and treatment decision-
making biases on cancer adverse effects among …
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psnet.ahrq.gov/node/43590/psn-pdf
October 08, 2014 - Disentangling quality and safety indicator data: a
longitudinal, comparative study of hand hygiene
compliance and accreditation outcomes in 96 Australian
hospitals.
October 8, 2014
Mumford V, Greenfield D, Hogden A, et al. Disentangling quality and safety indicator data: a longitudinal,
comparative study of hand …
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psnet.ahrq.gov/node/44522/psn-pdf
June 21, 2016 - Impact of an electronic alert notification system
embedded in radiologists' workflow on closed-loop
communication of critical results: a time series analysis.
June 21, 2016
Lacson R, O'Connor SD, Sahni A, et al. Impact of an electronic alert notification system embedded in
radiologists' workflow on closed-loop com…
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psnet.ahrq.gov/node/43788/psn-pdf
February 25, 2015 - Evaluating ambulatory practice safety: the PROMISES
Project administrators and practice staff surveys.
February 25, 2015
Singer SJ, Nieva HR, Brede N, et al. Evaluating ambulatory practice safety: the PROMISES project
administrators and practice staff surveys. Med Care. 2015;53(2):141-52.
doi:10.1097/MLR.000000000…
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psnet.ahrq.gov/node/46515/psn-pdf
December 22, 2018 - A contemporary medicolegal analysis of outpatient
medication management in chronic pain.
December 22, 2018
Abrecht CR, Brovman EY, Greenberg P, et al. A Contemporary Medicolegal Analysis of Outpatient
Medication Management in Chronic Pain. Anesth Analg. 2017;125(5):1761-1768.
doi:10.1213/ANE.0000000000002499.
htt…
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psnet.ahrq.gov/node/41967/psn-pdf
May 10, 2013 - A comparative review of patient safety initiatives for
national health information technology.
May 10, 2013
Magrabi F, Aarts J, Nohr C, et al. A comparative review of patient safety initiatives for national health
information technology. Int J Med Inform. 2013;82(5):e139-48. doi:10.1016/j.ijmedinf.2012.11.014.
htt…
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psnet.ahrq.gov/node/43170/psn-pdf
December 12, 2014 - Effects of patient-, environment- and medication-related
factors on high-alert medication incidents.
December 12, 2014
Manias E, Williams A, Liew D, et al. Effects of patient-, environment- and medication-related factors on
high-alert medication incidents. Int J Qual Health Care. 2014;26(3):308-20. doi:10.1093/intq…
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psnet.ahrq.gov/node/45310/psn-pdf
January 03, 2017 - Minding the gaps: assessing communication outcomes of
electronic preconsultation exchange.
January 3, 2017
Price EL, Sewell JL, Chen AH, et al. Minding the Gaps: Assessing Communication Outcomes of Electronic
Preconsultation Exchange. Jt Comm J Qual Patient Saf. 2016;42(8):341-54.
https://psnet.ahrq.gov/issue/mind…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case April 2006
Is the “Surgical Personality” a Threat to Patient Safety?
Source and Credits
This presentation is based on the April 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary …
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psnet.ahrq.gov/continuing-education
February 26, 2025 - attack (TIA) – particularly in a young, healthy adult, and the limitations of non-contrast brain CT for identifying
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psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
November 25, 2020 - responsible for at least 3.2% of colonic perforations requiring surgical intervention. 2 The importance of identifying
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psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
November 27, 2019 - Active surveillance of medication pump entry data and guardrail overrides can assist in identifying new
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psnet.ahrq.gov/node/867475/psn-pdf
February 26, 2025 - Identifying missed clinical opportunities in delivery of overdose
prevention and naloxone prescription
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psnet.ahrq.gov/web-mm/hard-swallow
April 26, 2023 - assessment ( 15 ) by understanding communication processes, learning where they are subject to fail, and identifying
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psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
February 20, 2019 - and where algorithmic monitoring of large volumes of data is complementary to the clinical skill of identifying