-
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…
-
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…
-
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…
-
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…
-
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…
-
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…
-
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…
-
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…
-
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…
-
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.…
-
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…
-
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…
-
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
…
-
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…
-
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…
-
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…
-
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…
-
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…
-
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…
-
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…