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psnet.ahrq.gov/issue/error-reporting-preventive-force
June 11, 2014 - Commentary
Error reporting as a preventive force.
Citation Text:
Simpson RL. Error reporting as a preventive force. Nurs Manage. 2005;36(6):21-24, 56.
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psnet.ahrq.gov/issue/enhancing-prescription-medicine-adherence-national-plan
April 28, 2021 - Book/Report
Enhancing Prescription Medicine Adherence: A National Plan.
Citation Text:
Enhancing Prescription Medicine Adherence: A National Plan. Rockville, MD: National Council on Patient Information and Education; 2007.
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psnet.ahrq.gov/issue/improving-patient-safety-human-factors-methods
June 12, 2019 - United States Meeting/Conference
Improving Patient Safety with Human Factors Methods.
Citation Text:
Improving Patient Safety with Human Factors Methods. Armstrong Institute for Patient Safety and Quality, Baltimore, MD. April 17-18, 2025.
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psnet.ahrq.gov/issue/beyond-patient-safety-flatland
September 04, 2024 - Commentary
Beyond patient safety Flatland.
Citation Text:
Braithwaite J, Coiera E. Beyond patient safety Flatland. J R Soc Med. 2010;103(6):219-25. doi:10.1258/jrsm.2010.100032.
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psnet.ahrq.gov/issue/ethics-governance-artificial-intelligence-health
August 18, 2021 - Book/Report
Ethics & Governance of Artificial Intelligence for Health.
Citation Text:
Ethics & Governance of Artificial Intelligence for Health. Health Ethics & Governance, World Health Organization. Geneva, Switzerland: World Health Organization; 2021. ISBN: 9789240029200…
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psnet.ahrq.gov/issue/requires-dhss-make-reported-information-about-certain-adverse-events-publicly-available
January 31, 2018 - Legislation/Case Law
Requires DHSS to make reported information about certain adverse events publicly available.
Citation Text:
Requires DHSS to make reported information about certain adverse events publicly available. 212 New Jersey Legislature. Assembly, No. 4327. June 11, 2017.
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psnet.ahrq.gov/issue/nhs-safety-thermometer-report-patient-harms-and-harm-free-care-november-2014-november-2015
July 08, 2021 - Book/Report
NHS Safety Thermometer Reports.
Citation Text:
NHS Safety Thermometer Reports. Leeds, UK: Clinical Support Audit Unit, Health and Social Care Information Centre. 2012-2017.
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/node/33619/psn-pdf
September 01, 2005 - In Conversation with…Carolyn Clancy, MD
September 1, 2005
In Conversation with…Carolyn Clancy, MD. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
Editor's Note: Dr. Carolyn Clancy has been the Director of the Agency for Healthcare Research and
Quality (AHRQ) since 200…
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psnet.ahrq.gov/node/49521/psn-pdf
September 12, 2006 - A Troubling Amine
September 1, 2006
Flynn EA. A Troubling Amine. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/troubling-amine
The Case
A 43-year-old woman was admitted to the intensive care unit for symptoms of heart and respiratory failure.
She was found to have severe mitral and tricuspid valve regurgi…
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psnet.ahrq.gov/node/33794/psn-pdf
November 01, 2015 - In Conversation With… Lorri Zipperer, MA
November 1, 2015
In Conversation With… Lorri Zipperer, MA. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-lorri-zipperer-ma
Editor's note: Lorri Zipperer, principal at Zipperer Project Management, was a founding staff member of
the National Patient…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
February 01, 2017 - PowerPoint Presentation
Spotlight
The Hazards of Distraction: Ticking All the EHR Boxes
*
Source and Credits
This presentation is based on the February 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Anthony C. Easty, PhD, Adjunct Pr…
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psnet.ahrq.gov/node/47474/psn-pdf
April 07, 2019 - Toward safer health care: a review strategy of FDA
medical device adverse event database to identify and
categorize health information technology related events.
April 7, 2019
Kang H, Wang J, Yao B, et al. Toward safer health care: a review strategy of FDA medical device adverse
event database to identify and cate…
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psnet.ahrq.gov/node/862991/psn-pdf
February 21, 2024 - Exploring the role of guidelines in contributing to
medication errors: a descriptive analysis of national
patient safety incident data.
February 21, 2024
Jones MD, Liu S, Powell F, et al. Exploring the role of guidelines in contributing to medication errors: a
descriptive analysis of national patient safety incide…
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psnet.ahrq.gov/node/33571/psn-pdf
March 15, 2025 - Reporting Patient Safety Events
March 15, 2025
Reporting Patient Safety Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/reporting-patient-safety-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in th…
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psnet.ahrq.gov/primer/handoffs
October 18, 2023 - Handoffs
Citation Text:
Handoffs and Signouts. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/issue/scaling-pharmacist-led-information-technology-intervention-pincer-reduce-hazardous
December 16, 2020 - Study
Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: multiple interrupted time series study.
Citation Text:
Rodgers S, Taylor AC, Roberts SA, et al. Scaling-up a pharmacist-led information technology interven…
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psnet.ahrq.gov/issue/how-context-affects-electronic-health-record-based-test-result-follow-mixed-methods
April 04, 2011 - Study
How context affects electronic health record–based test result follow-up: a mixed-methods evaluation.
Citation Text:
Menon S, Smith MW, Sittig DF, et al. How context affects electronic health record-based test result follow-up: a mixed-methods evaluation. BMJ Open. 2014;4(11):e0059…
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psnet.ahrq.gov/issue/problem-list-completeness-electronic-health-records-multi-site-study-and-assessment-success
April 29, 2018 - Study
Problem list completeness in electronic health records: a multi-site study and assessment of success factors.
Citation Text:
Wright A, McCoy AB, Hickman T-TT, et al. Problem list completeness in electronic health records: A multi-site study and assessment of success factors. Int J …
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psnet.ahrq.gov/issue/effect-postdischarge-virtual-ward-readmission-or-death-high-risk-patients-randomized-clinical
October 31, 2011 - Study
Classic
Effect of a postdischarge virtual ward on readmission or death for high-risk patients: a randomized clinical trial.
Citation Text:
Dhalla IA, O'Brien T, Morra D, et al. Effect of a postdischarge virtual ward on readmission or death for high-risk pa…