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psnet.ahrq.gov/issue/hospital-rules-based-system-next-generation-medical-informatics-patient-safety
April 21, 2010 - Study
Hospital rules-based system: the next generation of medical informatics for patient safety.
Citation Text:
Wilson JW, Oyen LJ, Ou NN, et al. Hospital rules-based system: the next generation of medical informatics for patient safety. Am J Health Syst Pharm. 2005;62(5):499-505.
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psnet.ahrq.gov/issue/methicillin-resistant-staphylococcus-aureus-disease-three-communities
July 03, 2014 - Study
Methicillin-resistant Staphylococcus aureus disease in three communities.
Citation Text:
Fridkin SK, Hageman JC, Morrison M, et al. Methicillin-resistant Staphylococcus aureus disease in three communities. N Engl J Med. 2005;352(14):1436-44.
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psnet.ahrq.gov/issue/reasons-provided-prescribers-when-overriding-drug-drug-interaction-alerts
April 27, 2010 - Study
Reasons provided by prescribers when overriding drug–drug interaction alerts.
Citation Text:
Grizzle AJ, Mahmood MH, Ko Y, et al. Reasons provided by prescribers when overriding drug-drug interaction alerts. Am J Manag Care. 2007;13(10):573-578.
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psnet.ahrq.gov/issue/systematic-review-effectiveness-compliance-and-critical-factors-implementation-safety
December 04, 2024 - Review
A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery.
Citation Text:
Borchard A, Schwappach DLB, Barbir A, et al. A systematic review of the effectiveness, compliance, and critical factors for implementatio…
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psnet.ahrq.gov/issue/dealing-unforeseen-complexity-or-role-heedful-interrelating-medical-teams
July 06, 2011 - Study
Dealing with unforeseen complexity in the OR: the role of heedful interrelating in medical teams.
Citation Text:
Schraagen JM. Dealing with unforeseen complexity in the OR: the role of heedful interrelating in medical teams. Theor Issues Ergon Sci. 2011;12(3). doi:10.1080/1464536…
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psnet.ahrq.gov/issue/use-safety-attitudes-questionnaire-measure-patient-safety-improvement
August 18, 2010 - Study
Use of the Safety Attitudes Questionnaire as a measure in patient safety improvement.
Citation Text:
Watts B, Percarpio KB, West P, et al. Use of the Safety Attitudes Questionnaire as a measure in patient safety improvement. J Patient Saf. 2010;6(4):206-9.
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psnet.ahrq.gov/issue/cost-implications-actual-and-potential-adverse-events-prevented-interventions-critical-care
June 28, 2010 - Study
Cost implications of actual and potential adverse events prevented by interventions of a critical care pharmacist.
Citation Text:
Kopp BJ, Mrsan M, Erstad BL, et al. Cost implications of and potential adverse events prevented by interventions of a critical care pharmacist. Am J H…
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psnet.ahrq.gov/issue/using-medicolegal-data-support-safe-medical-care-contributing-factor-coding-framework
April 03, 2024 - Commentary
Using medicolegal data to support safe medical care: a contributing factor coding framework.
Citation Text:
McCleery A, Devenny K, Ogilby C, et al. Using medicolegal data to support safe medical care: A contributing factor coding framework. J Healthc Risk Manag. 2019;38(4):11-…
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psnet.ahrq.gov/issue/surgical-skill-predicted-ability-detect-errors
September 02, 2020 - Study
Surgical skill is predicted by the ability to detect errors.
Citation Text:
Bann S, Khan M, Datta V, et al. Surgical skill is predicted by the ability to detect errors. Am J Surg. 2005;189(4):412-5.
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psnet.ahrq.gov/issue/role-anesthesia-surgical-mortality
July 19, 2023 - Study
Classic
The role of anesthesia in surgical mortality.
Citation Text:
DRIPPS RD, LAMONT A, ECKENHOFF JE. The role of anesthesia in surgical mortality. JAMA. 1961;178:261-6.
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psnet.ahrq.gov/issue/transmitting-and-processing-electronic-prescriptions-experiences-physician-practices-and
July 02, 2019 - Study
Transmitting and processing electronic prescriptions: experiences of physician practices and pharmacies.
Citation Text:
Grossman JM, Cross DA, Boukus ER, et al. Transmitting and processing electronic prescriptions: experiences of physician practices and pharmacies. J Am Med Inform …
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psnet.ahrq.gov/issue/rapid-response-team-rural-hospital
October 19, 2022 - Study
Rapid response team in a rural hospital.
Citation Text:
Brown S, Anderson MA, Hill PD. Rapid response team in a rural hospital. Clin Nurse Spec. 2012;26(2):95-102. doi:10.1097/NUR.0b013e31824590fb.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML…
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psnet.ahrq.gov/issue/nature-and-occurrence-registration-errors-emergency-department
September 28, 2016 - Study
The nature and occurrence of registration errors in the emergency department.
Citation Text:
Hakimzada AF, Green RA, Sayan OR, et al. The nature and occurrence of registration errors in the emergency department. Int J Med Inform. 2007;77(3). doi:10.1016/j.ijmedinf.2007.04.011.
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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - What Happened on Telemetry?
April 1, 2019
Sandau KE, Funk M. What Happened on Telemetry? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/what-happened-telemetry
Case Objectives
Describe current hospital practices for continuous telemetry monitoring.
Appreciate key recommendations from the Update to Practice…
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psnet.ahrq.gov/node/73336/psn-pdf
May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping
Healthcare Providers
May 26, 2021
Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
The Case
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psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
February 26, 2025 - U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument
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January …
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psnet.ahrq.gov/node/33784/psn-pdf
April 01, 2015 - In Conversation With… David Urbach, MD, MSc
April 1, 2015
In Conversation With… David Urbach, MD, MSc. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-david-urbach-md-msc
Editor's note: Dr. David Urbach is Professor of Surgery and Health Policy, Management, and Evaluation
at the University…
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psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
April 01, 2015 - SPOTLIGHT CASE
Pseudo-obstruction But a Real Perforation
Citation Text:
Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - SPOTLIGHT CASE
Bad Writing, Wrong Medication
Citation Text:
Devine B. Bad Writing, Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
June 24, 2020 - SPOTLIGHT CASE
Impatient Inpatient Dosing
Citation Text:
White RH. Impatient Inpatient Dosing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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