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psnet.ahrq.gov/node/46825/psn-pdf
June 19, 2018 - Diagnostic performance dashboards: tracking diagnostic
errors using big data.
June 19, 2018
Mane KK, Rubenstein KB, Nassery N, et al. Diagnostic performance dashboards: tracking diagnostic errors
using big data. BMJ Qual Saf. 2018;27(7):567-570. doi:10.1136/bmjqs-2018-007945.
https://psnet.ahrq.gov/issue/diagnosti…
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psnet.ahrq.gov/node/48034/psn-pdf
May 22, 2019 - Chasing zero harm in radiation oncology: using pre-
treatment peer review.
May 22, 2019
Vijayakumar S, Duggar WN, Packianathan S, et al. Chasing Zero Harm in Radiation Oncology: Using Pre-
treatment Peer Review. Front Oncol. 2019;9:302. doi:10.3389/fonc.2019.00302.
https://psnet.ahrq.gov/issue/chasing-zero-harm-ra…
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psnet.ahrq.gov/node/866857/psn-pdf
October 02, 2024 - Reducing falls in hospitalized children and adolescents
with cancer and blood disorders: a quality improvement
journey.
October 2, 2024
Morrissey LK, Ho P, Ilowite M, et al. Reducing falls in hospitalized children and adolescents with cancer
and blood disorders: a quality improvement journey. Pediatr Qual Saf. 202…
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psnet.ahrq.gov/node/47802/psn-pdf
March 04, 2019 - The path to diagnostic excellence includes feedback to
calibrate how clinicians think.
March 4, 2019
Meyer AND, Singh H. The Path to Diagnostic Excellence Includes Feedback to Calibrate How Clinicians
Think. JAMA. 2019;321(8):737-738. doi:10.1001/jama.2019.0113.
https://psnet.ahrq.gov/issue/path-diagnostic-excelle…
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psnet.ahrq.gov/node/47279/psn-pdf
July 23, 2018 - No Place Like Home: Advancing the Safety of Care in the
Home.
July 23, 2018
Boston, MA: Institute for Healthcare Improvement; 2018.
https://psnet.ahrq.gov/issue/no-place-home-advancing-safety-care-home
The home care setting harbors unique challenges to patient safety. This report builds on a previous
evidence ass…
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psnet.ahrq.gov/node/853074/psn-pdf
February 06, 2024 - Patient Experience, Patient Safety, and Provider Well-
Being: Associations and Paths for Quality Improvement.
February 6, 2024
Rockville, MD: Agency for Healthcare Research and Quality; January 2024. AHRQ Publication no.
24-0030.
https://psnet.ahrq.gov/issue/patient-experience-patient-safety-and-provider-well…
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psnet.ahrq.gov/node/48070/psn-pdf
July 17, 2019 - Controversies in diagnosis: contemporary debates in the
diagnostic safety literature.
July 17, 2019
Bergl PA, Wijesekera TP, Nassery N, et al. Controversies in diagnosis: contemporary debates in the
diagnostic safety literature. Diagnosis (Berl). 2020;7(1):3-9. doi:10.1515/dx-2019-0016.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/46474/psn-pdf
November 08, 2017 - Clearing the Error: Using Public Deliberation to Define
Patient Roles as Partners in the Diagnostic Process.
November 8, 2017
St. Paul, MN: Society to Improve Diagnosis in Medicine, Maxwell School of Citizenship and Public Affairs at
Syracuse University, and Jefferson Center; 2017.
https://psnet.ahrq.gov/issue/cle…
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psnet.ahrq.gov/node/74856/psn-pdf
February 23, 2022 - The secondary use of data to support medication safety
in the hospital setting: a systematic review and narrative
synthesis.
February 23, 2022
Chaudhry NT, Franklin BD, Mohammed S, et al. The secondary use of data to support medication safety in
the hospital setting: a systematic review and narrative synthesis. Ph…
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psnet.ahrq.gov/node/864371/psn-pdf
March 13, 2024 - The ritualisation of the surgical safety checklist and its
decoupling from patient safety goals.
March 13, 2024
Facey M, Baxter NN, Hammond Mobilio M, et al. The ritualisation of the surgical safety checklist and its
decoupling from patient safety goals. Sociol Health Illn. 2024;46(6):1100-1118. doi:10.1111/1467-
…
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psnet.ahrq.gov/node/45499/psn-pdf
May 03, 2017 - Patient safety and interprofessional education: a report of
key issues from two interprofessional workshops.
May 3, 2017
Anderson ES, Gray R, Price K. Patient safety and interprofessional education: A report of key issues from
two interprofessional workshops. J Interprof Care. 2017;31(2):154-163.
doi:10.1080/13561…
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psnet.ahrq.gov/node/43907/psn-pdf
April 27, 2015 - Association of hospital participation in a surgical
outcomes monitoring program with inpatient
complications and mortality.
April 27, 2015
Etzioni DA, Wasif N, Dueck AC, et al. Association of hospital participation in a surgical outcomes
monitoring program with inpatient complications and mortality. JAMA. 2015;313…
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psnet.ahrq.gov/node/47002/psn-pdf
April 25, 2018 - Making Health Care Safer in Ambulatory Care Settings
and Long Term Care Facilities (R18).
April 25, 2018
Rockville, MD: Agency for Healthcare Research and Quality; April 10, 2018. PA-18-750.
https://psnet.ahrq.gov/issue/making-health-care-safer-ambulatory-care-settings-and-long-term-care-
facilities-r18
Research …
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psnet.ahrq.gov/node/857450/psn-pdf
January 01, 2024 - Transforming team performance through
reimplementation of the surgical safety checklist.
December 6, 2023
Etheridge JC, Moyal-Smith R, Yong TT, et al. Transforming team performance through reimplementation of
the surgical safety checklist. JAMA Surg. 2024;159(1):78-86. doi:10.1001/jamasurg.2023.5400.
https://psnet…
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psnet.ahrq.gov/node/33583/psn-pdf
March 01, 2023 - Simulation Training
March 1, 2023
Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/simulation-training
Originally published in 2014 by researchers at the University of California, San Francisco. Updated in
March 2023, by Jennifer J. Edwards, MS, RN, CHSE…
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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - SPOTLIGHT CASE
Dangerous Shift
Citation Text:
Patterson ES. Dangerous Shift. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Patient Safety Events Involving Opioid
Dose Stacking
Source and Credits
• This presentation is based on the January 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…
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psnet.ahrq.gov/node/72689/psn-pdf
January 29, 2021 - But See the Patient First
January 29, 2021
Sinigayan VR. But See the Patient First. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/see-patient-first
The Case
A 55-year-old man with acute myeloid leukemia presented to the emergency department (ED) with a chief
complaint of fever. Five days previously, he …
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psnet.ahrq.gov/primers-0
March 15, 2025 - Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Latest Primers
Clinical Decision Support Systems
March…
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psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and-intervention-innovation
July 23, 2024 - System Approaches to Social Determinants of Health Screening and Intervention Innovation Summary
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