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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46082/psn-pdf
    February 25, 2019 - The opioid crisis: can improving diagnosis help solve the problem? February 25, 2019 Carr S. ImproveDx. April 2017;4:1-4. https://psnet.ahrq.gov/issue/opioid-crisis-can-improving-diagnosis-help-solve-problem The opioid epidemic has been widely discussed, but little research has examined how misdiagnosis can contr…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39218/psn-pdf
    January 13, 2010 - Prolonged hospital stay and the resident duty hour rules of 2003. January 13, 2010 Silber JH, Rosenbaum PR, Rosen AK, et al. Prolonged Hospital Stay and the Resident Duty Hour Rules of 2003. Med Care. 2009;47(12). doi:10.1097/mlr.0b013e3181adcbff. https://psnet.ahrq.gov/issue/prolonged-hospital-stay-and-resident-d…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43116/psn-pdf
    April 09, 2014 - A growing number of primary-care doctors are burning out. How does this affect patients? April 9, 2014 Rabin RC, Kaiser Health News. Washington Post. March 31, 2014. https://psnet.ahrq.gov/issue/growing-number-primary-care-doctors-are-burning-out-how-does-affect- patients This newspaper article reports on factors…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37135/psn-pdf
    October 04, 2011 - Combining ratings from multiple physician reviewers helped to overcome the uncertainty associated with adverse event classification. October 4, 2011 Forster AJ, O'Rourke K, Shojania KG, et al. Combining ratings from multiple physician reviewers helped to overcome the uncertainty associated with adverse event class…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35176/psn-pdf
    June 23, 2009 - Mapping changes in surgical mortality over 9 years by peer review audit. June 23, 2009 Thompson A, Ashraf Z, Burton H, et al. Mapping changes in surgical mortality over 9 years by peer review audit. Br J Surg. 2005;92(11):1449-52. https://psnet.ahrq.gov/issue/mapping-changes-surgical-mortality-over-9-years-peer-re…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39838/psn-pdf
    September 15, 2010 - A multicenter trial of aviation-style training for surgical teams. September 15, 2010 Catchpole K, Dale TJ, Hirst G, et al. A multicenter trial of aviation-style training for surgical teams. J Patient Saf. 2010;6(3):180-6. doi:10.1097/PTS.0b013e3181f100ea. https://psnet.ahrq.gov/issue/multicenter-trial-aviation-st…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74232/psn-pdf
    January 12, 2022 - Intersystem medical error discovery: a document analysis of ethical guidelines. January 12, 2022 Duffy B, Miller J, Vitous CA, et al. Intersystem medical error discovery: a document analysis of ethical guidelines. J Patient Saf. 2021;17(8):e1765-e1773. doi:10.1097/pts.0000000000000625. https://psnet.ahrq.gov/issue…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42893/psn-pdf
    March 13, 2014 - Effect of patient safety strategies on the incidence of adverse events. March 13, 2014 Sierra AF, del Aguila del MR, Espigares JLN, et al. Effect of patient safety strategies on the incidence of adverse events. J Eval Clin Pract. 2014;20(2):184-90. doi:10.1111/jep.12105. https://psnet.ahrq.gov/issue/effect-patient…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35244/psn-pdf
    December 17, 2008 - Representative case series from public hospital admissions 1998 II: surgical adverse events. December 17, 2008 Briant R, Morton J, Lay-Yee R, et al. Representative case series from public hospital admissions 1998 II: surgical adverse events. N Z Med J. 2005;118(1219):U1591. https://psnet.ahrq.gov/issue/representat…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40545/psn-pdf
    June 22, 2011 - Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes. June 22, 2011 Effken JA, Carley KM, Gephart SM, et al. Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes. Int J Med Inform. 2011;80(7):507-17. doi:10.…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837608/psn-pdf
    September 06, 2023 - Harm Caused by Delays in Transferring Patients to the Right Place of Care. September 6, 2023 Farnborough, UK: Healthcare Safety Investigation Branch; August 2023. https://psnet.ahrq.gov/issue/harm-caused-delays-transferring-patients-right-place-care Handoffs between prehospital emergency medical services (EMS) pro…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846445/psn-pdf
    March 22, 2023 - Formalizing the hidden curriculum of performance enhancing errors. March 22, 2023 Kerray FM, Yule SJ, Tambyraja AL. Formalizing the hidden curriculum of performance enhancing errors. J Surg Educ. 2023;80(5):619-623. doi:10.1016/j.jsurg.2023.01.009. https://psnet.ahrq.gov/issue/formalizing-hidden-curriculum-perform…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43517/psn-pdf
    October 08, 2014 - The cost of opioid–related adverse drug events. October 8, 2014 Kane-Gill SL, Rubin EC, Smithburger PL, et al. The cost of opioid-related adverse drug events. J Pain Palliat Care Pharmacother. 2014;28(3):282-93. doi:10.3109/15360288.2014.938889. https://psnet.ahrq.gov/issue/cost-opioid-related-adverse-drug-events …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50671/psn-pdf
    November 20, 2019 - Critical errors in infrequently performed trauma procedures after training. November 20, 2019 Mackenzie CF, Shackelford SA, Tisherman SA, et al. Critical errors in infrequently performed trauma procedures after training. Surgery. 2019;166(5):835-843. doi:10.1016/j.surg.2019.05.031. https://psnet.ahrq.gov/issue/cri…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43648/psn-pdf
    November 21, 2016 - Patient- and family-centered care: error disclosure and investigation. November 21, 2016 Connor M; Wayman KI; Garcia C; Fischer PR; Consortium for Maximizing Family-Centered Care. https://psnet.ahrq.gov/issue/patient-and-family-centered-care-error-disclosure-and-investigation Patients are increasingly encouraged t…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844556/psn-pdf
    February 15, 2023 - Using Machine Learning to Improve Patient Safety in the Home or Remote Setting for Adults. February 15, 2023 Feske-Kirby K, Whittington J, McGaffigan P. Boston, MA: Institute for Healthcare Improvement; 2022. https://psnet.ahrq.gov/issue/using-machine-learning-improve-patient-safety-home-or-remote-setting-adults T…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44525/psn-pdf
    October 21, 2015 - Wound-care teams for preventing and treating pressure ulcers. October 21, 2015 Moore ZEH, Webster J, Samuriwo R. Wound-care teams for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2015;9:CD011011. doi:10.1002/14651858.CD011011.pub2. https://psnet.ahrq.gov/issue/wound-care-teams-preventing-an…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43740/psn-pdf
    December 10, 2014 - Participation in EHR based simulation improves recognition of patient safety issues. December 10, 2014 Stephenson LS, Gorsuch A, Hersh WR, et al. Participation in EHR based simulation improves recognition of patient safety issues. BMC Med Educ. 2014;14:224. doi:10.1186/1472-6920-14-224. https://psnet.ahrq.gov/issu…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849609/psn-pdf
    May 31, 2023 - Impact of diagnostic checklists on the interpretation of normal and abnormal electrocardiograms. May 31, 2023 Staal J, Zegers R, Caljouw-Vos J, et al. Impact of diagnostic checklists on the interpretation of normal and abnormal electrocardiograms. Diagnosis (Berl). 2022;10(2):121-129. doi:10.1515/dx-2022-0092. htt…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41105/psn-pdf
    December 16, 2013 - Patients' attitudes towards patient involvement in safety interventions: results of two exploratory studies. December 16, 2013 Davis R, Sevdalis N, Pinto A, et al. Patients' attitudes towards patient involvement in safety interventions: results of two exploratory studies. Health Expect. 2013;16(4):e164-76. doi:10.1…