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psnet.ahrq.gov/node/44996/psn-pdf
June 29, 2016 - Residents' numeric inputting error in computerized
physician order entry prescription.
June 29, 2016
Wu X, Wu C, Zhang K, et al. Residents' numeric inputting error in computerized physician order entry
prescription. Int J Med Inform. 2016;88:25-33. doi:10.1016/j.ijmedinf.2016.01.002.
https://psnet.ahrq.gov/issue/r…
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psnet.ahrq.gov/node/41606/psn-pdf
February 01, 2019 - Safe use of opioids in hospitals.
December 23, 2016
Sentinel Event Alert. 2012;49:1-5.
https://psnet.ahrq.gov/issue/safe-use-opioids-hospitals
Opioid pain medications are considered high-risk medications due to the potential for respiratory
depression and other adverse effects. Because these medications are freque…
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psnet.ahrq.gov/node/46094/psn-pdf
July 11, 2017 - Hiding in plain sight—resurrecting the power of
inspecting the patient.
July 11, 2017
Gupta S, Saint S, Detsky AS. Hiding in Plain Sight-Resurrecting the Power of Inspecting the Patient. JAMA
Intern Med. 2017;177(6):757-758. doi:10.1001/jamainternmed.2017.0634.
https://psnet.ahrq.gov/issue/hiding-plain-sight-resur…
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psnet.ahrq.gov/node/837597/psn-pdf
June 29, 2022 - Patient safety informatics: criteria development for
assessing the maturity of digital patient safety in
hospitals.
June 29, 2022
Kutza J-O, Hübner U, Holmgren AJ, et al. Patient safety informatics: criteria development for assessing the
maturity of digital patient safety in hospitals. Stud Health Technol Inform. …
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psnet.ahrq.gov/node/47279/psn-pdf
July 23, 2018 - No Place Like Home: Advancing the Safety of Care in the
Home.
July 23, 2018
Boston, MA: Institute for Healthcare Improvement; 2018.
https://psnet.ahrq.gov/issue/no-place-home-advancing-safety-care-home
The home care setting harbors unique challenges to patient safety. This report builds on a previous
evidence ass…
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psnet.ahrq.gov/node/37277/psn-pdf
July 28, 2010 - Drug selection errors in relation to medication labels: a
simulation study.
July 28, 2010
Garnerin P, Perneger T, Chopard P, et al. Drug selection errors in relation to medication labels: a
simulation study. Anaesthesia. 2007;62(11):1090-4.
https://psnet.ahrq.gov/issue/drug-selection-errors-relation-medication-lab…
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psnet.ahrq.gov/node/35838/psn-pdf
March 28, 2011 - Unscheduled returns to the emergency department: an
outcome of medical errors?
March 28, 2011
Nuñez S, Hexdall A, Aguirre-Jaime A. Unscheduled returns to the emergency department: an outcome of
medical errors? Qual Saf Health Care. 2006;15(2):102-8.
https://psnet.ahrq.gov/issue/unscheduled-returns-emergency-depart…
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psnet.ahrq.gov/perspective/conversation-andrew-bindman-md
June 15, 2024 - In Conversation With… Andrew Bindman, MD
November 1, 2016
Citation Text:
In Conversation With… Andrew Bindman, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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For…
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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/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/49771/psn-pdf
July 01, 2016 - Unintended Consequences of CPOE
October 1, 2016
Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
Case Objectives
Explain how technology, including computerized provider order entry, can transform, rather than
eliminate, hazards.
Recogni…
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psnet.ahrq.gov/curated-library/artificial-intelligence-system-level-considerations
March 27, 2024 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Artificial Intelligence: System-Level Considerations
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Created By: Lorri Zipper…
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psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
May 31, 2023 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
Citation Text:
In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/850675/psn-pdf
June 14, 2023 - Patient and Family Roles in Safety
June 14, 2023
Johnson B, Lee M, Mossburg S. Patient and Family Roles in Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/patient-and-family-roles-safety
Moving From Engagement to Partnership
Involving patients and families in healthcare decisions about patient c…
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psnet.ahrq.gov/toolkits
March 01, 2025 - Toolkits
Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols.
Want to submit a Toolkit?
Has your organization deve…
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psnet.ahrq.gov/node/49819/psn-pdf
February 01, 2018 - Signout Fallout
February 1, 2018
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/signout-fallout
Case Objectives
Understand the role of communication failures in medical errors and preventable adverse events.
Review the evidence in support of handoff improvement pr…
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psnet.ahrq.gov/node/33818/psn-pdf
November 01, 2016 - In Conversation With… Andrew Bindman, MD
November 1, 2016
In Conversation With… Andrew Bindman, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-andrew-bindman-md
Editor's note: Dr. Bindman was appointed as Director of the Agency for Healthcare Research and Quality
(AHRQ) in May 2016. P…
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psnet.ahrq.gov/web-mm/techno-trip
May 01, 2005 - Techno Trip
Citation Text:
Cook RI. Techno Trip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/60826/psn-pdf
August 19, 2020 - Variation in electronic test results management and its
implications for patient safety: a multisite investigation.
August 19, 2020
Thomas J, Dahm MR, Li J, et al. Variation in electronic test results management and its implications for
patient safety: a multisite investigation. J Am Med Inform Assoc. 2020;27(8):12…
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psnet.ahrq.gov/node/73063/psn-pdf
March 24, 2021 - Clinical data sharing improves quality measurement and
patient safety.
March 24, 2021
D’Amore JD, McCrary LK, Denson J, et al. Clinical data sharing improves quality measurement and patient
safety. J Am Med Inform Assoc. 2021;28(7):1534-1542. doi:10.1093/jamia/ocab039.
https://psnet.ahrq.gov/issue/clinical-data-sh…