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psnet.ahrq.gov/node/44660/psn-pdf
December 02, 2015 - The SQUIRE Guidelines: an evaluation from the field, 5
years post release.
December 2, 2015
Davies L, Batalden P, Davidoff F, et al. The SQUIRE Guidelines: an evaluation from the field, 5 years post
release. BMJ Qual Saf. 2015;24(12):769-75. doi:10.1136/bmjqs-2015-004116.
https://psnet.ahrq.gov/issue/squire-guidel…
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psnet.ahrq.gov/node/45581/psn-pdf
October 19, 2016 - Reducing diagnostic errors.
October 19, 2016
Gittlen S. HealthLeaders Media. October 1, 2016.
https://psnet.ahrq.gov/issue/reducing-diagnostic-errors-0
The recent recognition of diagnostic error as a blind spot in health care has driven the need to enhance
diagnosis. This news article reports how health systems, a…
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psnet.ahrq.gov/node/844540/psn-pdf
February 15, 2023 - Health technology, quality and safety in a learning health
system.
February 15, 2023
Borycki EM, Kushniruk AW. Health technology, quality and safety in a learning health system. Healthc
Manage Forum. 2023;51(2):212-221. doi:10.1177/08404704221139383.
https://psnet.ahrq.gov/issue/health-technology-quality-and-safet…
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psnet.ahrq.gov/node/49446/psn-pdf
August 30, 2021 - Too Tight Control
May 1, 2004
Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/too-tight-control
Case Objectives
Appreciate the advantages and potential complications of intensive insulin therapy in the hospitalized
patient
List hospital-based safeguards available to…
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psnet.ahrq.gov/node/49787/psn-pdf
March 01, 2017 - Diagnosing a Missed Diagnosis
March 1, 2017
Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
The Case
A 57-year old woman was admitted to the hospital with cough, slurred speech, confusion, and
disorientation. She was taking mod…
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psnet.ahrq.gov/node/33730/psn-pdf
June 01, 2012 - In Conversation With… Charles Vincent, MPhil, PhD
June 1, 2012
In Conversation With… Charles Vincent, MPhil, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-charles-vincent-mphil-phd
Editor's note: Charles Vincent, MPhil, PhD, a psychologist by training, is one of the world's leading p…
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psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - Patient Safety Indicators
Citation Text:
Tokareva I, Romano P. Patient Safety Indicators.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
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psnet.ahrq.gov/periodic-issue/periodic-issue-470
December 31, 2024 - January 15, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/issue/pharmacist-medication-reviews-improve-safety-monitoring-primary-care-patients
April 24, 2018 - Study
Pharmacist medication reviews to improve safety monitoring in primary care patients.
Citation Text:
Gallimore CE, Sokhal D, Schreiter EZ, et al. Pharmacist medication reviews to improve safety monitoring in primary care patients. Fam Syst Health. 2016;34(2):104-113. doi:10.1037/fsh…
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psnet.ahrq.gov/issue/academic-detailing-improve-laboratory-testing-among-outpatient-medication-users
September 24, 2010 - Study
Academic detailing to improve laboratory testing among outpatient medication users.
Citation Text:
Lafata JE, Gunter MJ, Hsu J, et al. Academic detailing to improve laboratory testing among outpatient medication users. Med Care. 2007;45(10):966-72.
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psnet.ahrq.gov/issue/improving-radiology-report-quality-rapidly-notifying-radiologist-report-errors
May 29, 2019 - Study
Improving radiology report quality by rapidly notifying radiologist of report errors.
Citation Text:
Minn MJ, Zandieh AR, Filice RW. Improving Radiology Report Quality by Rapidly Notifying Radiologist of Report Errors. J Digit Imaging. 2015;28(4):492-8. doi:10.1007/s10278-015-9781-…
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psnet.ahrq.gov/issue/procedural-timeout-compliance-improved-real-time-clinical-decision-support
October 11, 2017 - Study
Procedural timeout compliance is improved with real-time clinical decision support.
Citation Text:
Shear T, Deshur M, Avram MJ, et al. Procedural Timeout Compliance Is Improved With Real-Time Clinical Decision Support. J Patient Saf. 2018;14(3):148-152. doi:10.1097/PTS.000000000000…
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psnet.ahrq.gov/issue/adc-survey-shows-some-improvements-unnecessary-risks-still-exist
January 23, 2019 - Newspaper/Magazine Article
ADC survey shows some improvements, but unnecessary risks still exist.
Citation Text:
ADC survey shows some improvements, but unnecessary risks still exist. ISMP Medication Safety Alert! Acute care edition. January 17, 2008.
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psnet.ahrq.gov/issue/perinatal-care-quality-and-safety-initiative-are-there-financial-rewards-improved-quality
April 27, 2019 - Study
A perinatal care quality and safety initiative: are there financial rewards for improved quality?
Citation Text:
Kozhimannil KB, Sommerness SA, Rauk P, et al. A perinatal care quality and safety initiative: are there financial rewards for improved quality? Jt Comm J Qual Patient …
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psnet.ahrq.gov/issue/communication-critical-care-environments-mobile-telephones-improve-patient-care
June 27, 2018 - Study
Communication in critical care environments: mobile telephones improve patient care.
Citation Text:
Soto RG, Chu LF, Goldman JM, et al. Communication in critical care environments: mobile telephones improve patient care. Anesth Analg. 2006;102(2):535-41.
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psnet.ahrq.gov/issue/improving-critical-incident-reporting-primary-care-through-education-and-involvement
September 07, 2022 - Study
Improving critical incident reporting in primary care through education and involvement.
Citation Text:
Müller BS, Beyer M, Blazejewski T, et al. Improving critical incident reporting in primary care through education and involvement. BMJ Open Qual. 2019;8(3):e000556. doi:10.1136/b…
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psnet.ahrq.gov/issue/simulation-tool-improve-safety-pre-hospital-anaesthesia-pilot-study
October 19, 2022 - Study
Simulation as a tool to improve the safety of pre-hospital anaesthesia—a pilot study.
Citation Text:
Batchelder AJ, Steel A, Mackenzie R, et al. Simulation as a tool to improve the safety of pre-hospital anaesthesia--a pilot study. Anaesthesia. 2009;64(9):978-83. doi:10.1111/j.1365…
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psnet.ahrq.gov/issue/stories-clinicians-tell-achieving-high-reliability-and-improving-patient-safety
April 24, 2018 - Commentary
The stories clinicians tell: achieving high reliability and improving patient safety.
Citation Text:
Cohen DL, Stewart KO. The Stories Clinicians Tell: Achieving High Reliability and Improving Patient Safety. Perm J. 2016;20(1):85-90. doi:10.7812/TPP/15-039.
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psnet.ahrq.gov/issue/practical-approach-measure-quality-handwritten-medication-orders-tool-improvement
September 24, 2010 - Study
A practical approach to measure the quality of handwritten medication orders: a tool for improvement.
Citation Text:
Garbutt J, Milligan P, McNaughton C, et al. A Practical Approach to Measure the Quality of Handwritten Medication Orders. J Patient Saf. 2008;1(4). doi:10.1097/01.…
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psnet.ahrq.gov/issue/clinical-faculty-taking-lead-teaching-quality-improvement-and-patient-safety
July 01, 2017 - Commentary
Clinical faculty: taking the lead in teaching quality improvement and patient safety.
Citation Text:
Davis NL, Davis DA, Rayburn WF. Clinical faculty: taking the lead in teaching quality improvement and patient safety. Am J Obstet Gynecol. 2014;211(3):215-215.e1. doi:10.1016/j…