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psnet.ahrq.gov/node/45492/psn-pdf
September 28, 2016 - Understanding human over-reliance on technology.
September 28, 2016
ISMP Medication Safety Alert! Acute Care Edition. September 8, 2016;21:1-4.
https://psnet.ahrq.gov/issue/understanding-human-over-reliance-technology
Over-reliance on technology can contribute to error due to user complacency. Reviewing how the ten…
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psnet.ahrq.gov/node/47142/psn-pdf
June 13, 2018 - Managing health IT risks: reflections and
recommendations.
June 13, 2018
Sujan M. Managing health IT risks: reflections and recommendations. J Innov Health Inform.
2018;25(1):952. doi:10.14236/jhi.v25i1.952.
https://psnet.ahrq.gov/issue/managing-health-it-risks-reflections-and-recommendations
Health information t…
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psnet.ahrq.gov/web-mm/preventable-rash
October 01, 2012 - Preventable Rash
Citation Text:
McLean C. Preventable Rash. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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…
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psnet.ahrq.gov/node/49475/psn-pdf
March 01, 2005 - Techno Trip
March 1, 2005
Cook RI. Techno Trip. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/techno-trip
The Case
A 70-year-old woman was admitted to a community hospital after developing confusion and right-sided
weakness. A CT scan of her brain showed an acute subdural hematoma. The hospital arranged a…
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psnet.ahrq.gov/node/72807/psn-pdf
March 03, 2021 - Updated guidance needed for longstanding large volume
parenteral (LVP) labeling and packaging problems.
March 3, 2021
ISMP Medication Safety Alert! Acute care edition. February 11, 2021;26(3):1-4.
https://psnet.ahrq.gov/issue/updated-guidance-needed-longstanding-large-volume-parenteral-lvp-labeling-
and-packaging
…
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psnet.ahrq.gov/node/41968/psn-pdf
February 19, 2013 - Characterising physician listening behaviour during
hospitalist handoffs using the HEAR checklist.
February 19, 2013
Greenstein EA, Arora V, Staisiunas PG, et al. Characterising physician listening behaviour during
hospitalist handoffs using the HEAR checklist. BMJ Qual Saf. 2013;22(3):203-9. doi:10.1136/bmjqs-2012…
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psnet.ahrq.gov/node/36658/psn-pdf
May 27, 2011 - Potassium and phosphorus repletion in hospitalized
patients: implications for clinical practice and the
potential use of healthcare information technology to
improve prescribing and patient safety.
May 27, 2011
Hemstreet BA, Stolpman N, Badesch DB, et al. Potassium and phosphorus repletion in hospitalized
patient…
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psnet.ahrq.gov/node/836763/psn-pdf
March 16, 2022 - Maternity Pre-arrival Instructions by 999 Call Handlers.
March 16, 2022
Farnborough, UK: Healthcare Safety Investigation Branch; February 2022.
https://psnet.ahrq.gov/issue/maternity-pre-arrival-instructions-999-call-handlers
Pre-hospital emergency care can be vulnerable to timing, information, and task failures th…
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psnet.ahrq.gov/node/46427/psn-pdf
April 04, 2018 - Improving Diagnosis in Radiology—Progress and
Proposals.
April 4, 2018
Bruno MA, Johnson K, Argy N, Graber ML, eds. Diagnosis. 2017;4(3):111-191.
https://psnet.ahrq.gov/issue/improving-diagnosis-radiology-progress-and-proposals
Radiology plays a unique role in the determination of a diagnosis. Cognitive and system…
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psnet.ahrq.gov/node/846762/psn-pdf
March 29, 2023 - Hospital ‘black boxes’ put surgical practices under the
microscope.
March 29, 2023
Sadick B. Wall Street Journal. March 19, 2023.
https://psnet.ahrq.gov/issue/hospital-black-boxes-put-surgical-practices-under-microscope
Safety information systems that track action in real time can reveal a trove of data about how …
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psnet.ahrq.gov/node/74860/psn-pdf
February 23, 2022 - Is electronic health record safety a paradox?
February 23, 2022
Harrington L. Is electronic health record safety a paradox? AACN Adv Crit Care. 2021;32(4):375-380.
doi:10.4037/aacnacc2021406.
https://psnet.ahrq.gov/issue/electronic-health-record-safety-paradox
The usability of health information technology, such a…
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psnet.ahrq.gov/node/48043/psn-pdf
October 01, 2023 - Health Services Safety Investigations Body.
October 1, 2023
Lytchett House, 13 Freeland Park, Wareham Road, Poole, Dorset, BH16 6FA.
https://psnet.ahrq.gov/issue/health-services-safety-investigations-body
Independent investigations examine system weaknesses in health care to inform improvement, reduce risk,
and pr…
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psnet.ahrq.gov/web-mm/specimen-almost-lost
September 21, 2022 - Specimen Almost Lost
Citation Text:
Hehe YK. Specimen Almost Lost. 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/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
March 01, 2015 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay
Citation Text:
O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/73515/psn-pdf
August 01, 2022 - Missouri Quality Initiative (MOQI) Reduces
Hospitalizations Among Nursing Home Residents
July 28, 2021
https://psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-
home-residents
Summary
The MOQI seeks to reduce avoidable hospitalization among nursing home residents b…
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psnet.ahrq.gov/issue/people-processes-health-it-and-accurate-patient-identification
April 11, 2018 - Newspaper/Magazine Article
People, processes, health IT and accurate patient identification.
Citation Text:
People, processes, health IT and accurate patient identification. Quick Safety. October 1, 2018;(45):1-2.
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psnet.ahrq.gov/issue/managing-costs-clinical-negligence-trusts
March 28, 2018 - Book/Report
Managing the Costs of Clinical Negligence in Trusts.
Citation Text:
Managing the Costs of Clinical Negligence in Trusts. Comptroller and Auditor General, Department of Health; London, UK: National Audit Office; 2017. ISBN: 9781786041395.
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psnet.ahrq.gov/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error
June 10, 2018 - Newspaper/Magazine Article
Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.
Citation Text:
Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error. ISMP Medication Safety Alert! Acute care edition. August 26, 2010;15:1…
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psnet.ahrq.gov/issue/diagnosis-interpreting-shadows
June 29, 2016 - Book/Report
Diagnosis: Interpreting the Shadows.
Citation Text:
Diagnosis: Interpreting the Shadows. Croskerry P, Cosby KS, Graber ML, Singh H. Boca Raton, FL: CRC Press; 2017. ISBN: 9781409432333.
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psnet.ahrq.gov/issue/national-steering-committee-patient-safety
December 24, 2008 - Multi-use Website
National Steering Committee for Patient Safety.
Citation Text:
National Steering Committee for Patient Safety. Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement.
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