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psnet.ahrq.gov/node/38900/psn-pdf
January 03, 2017 - Dropping the baton during the handoff from emergency
department to primary care: pediatric asthma continuity
errors.
January 3, 2017
Hsiao AL, Shiffman RN. Dropping the baton during the handoff from emergency department to primary
care: pediatric asthma continuity errors. Jt Comm J Qual Patient Saf. 2009;35(9):467…
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psnet.ahrq.gov/node/40786/psn-pdf
December 30, 2014 - Exploring situational awareness in diagnostic errors in
primary care.
December 30, 2014
Singh H, Giardina TD, Petersen LA, et al. Exploring situational awareness in diagnostic errors in primary
care. BMJ Qual Saf. 2011;21(1):30-38. doi:10.1136/bmjqs-2011-000310.
https://psnet.ahrq.gov/issue/exploring-situational-a…
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psnet.ahrq.gov/node/47333/psn-pdf
October 10, 2018 - Changing dynamics of the drug overdose epidemic in the
United States from 1979 through 2016.
October 10, 2018
Jalal H, Buchanich JM, Roberts MS, et al. Changing dynamics of the drug overdose epidemic in the United
States from 1979 through 2016. Science (1979). 2018;361(6408). doi:10.1126/science.aau1184.
https://p…
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psnet.ahrq.gov/node/41049/psn-pdf
December 31, 2014 - Are physicians' perceptions of healthcare quality and
practice satisfaction affected by errors associated with
electronic health record use?
December 31, 2014
Love JS, Wright A, Simon SR, et al. Are physicians' perceptions of healthcare quality and practice
satisfaction affected by errors associated with electroni…
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psnet.ahrq.gov/node/38817/psn-pdf
April 04, 2011 - Adequacy of hospital discharge summaries in
documenting tests with pending results and outpatient
follow-up providers.
April 4, 2011
Were MC, Li X, Kesterson J, et al. Adequacy of hospital discharge summaries in documenting tests with
pending results and outpatient follow-up providers. J Gen Intern Med. 2009;24(9)…
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psnet.ahrq.gov/node/46975/psn-pdf
November 16, 2018 - Electronic health record usability issues and potential
contribution to patient harm.
November 16, 2018
Howe JL, Adams KT, Hettinger Z, et al. Electronic Health Record Usability Issues and Potential
Contribution to Patient Harm. JAMA. 2018;319(12):1276-1278. doi:10.1001/jama.2018.1171.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/42483/psn-pdf
January 22, 2014 - What patients think doctors know: beliefs about provider
knowledge as barriers to safe medication use.
January 22, 2014
Serper M, McCarthy D, Patzer RE, et al. What patients think doctors know: beliefs about provider
knowledge as barriers to safe medication use. Patient Educ Couns. 2013;93(2):306-11.
doi:10.1016/j…
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psnet.ahrq.gov/node/47666/psn-pdf
January 01, 2020 - A partially structured postoperative handoff protocol
improves communication in 2 mixed surgical intensive
care units: findings from the Handoffs and Transitions in
Critical Care (HATRICC) prospective cohort study.
February 6, 2019
Lane-Fall MB, Pascual JL, Peifer HG, et al. A Partially Structured Postoperative Ha…
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psnet.ahrq.gov/node/45310/psn-pdf
January 03, 2017 - Minding the gaps: assessing communication outcomes of
electronic preconsultation exchange.
January 3, 2017
Price EL, Sewell JL, Chen AH, et al. Minding the Gaps: Assessing Communication Outcomes of Electronic
Preconsultation Exchange. Jt Comm J Qual Patient Saf. 2016;42(8):341-54.
https://psnet.ahrq.gov/issue/mind…
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psnet.ahrq.gov/node/42628/psn-pdf
January 07, 2015 - Engaging patients in medication reconciliation via a
patient portal following hospital discharge.
January 7, 2015
Heyworth L, Paquin AM, Clark J, et al. Engaging patients in medication reconciliation via a patient portal
following hospital discharge. J Am Med Inform Assoc. 2014;21(e1):e157-62. doi:10.1136/amiajnl-2…
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psnet.ahrq.gov/node/39212/psn-pdf
March 04, 2011 - The impact of computerized provider order entry on
medication errors in a multispecialty group practice.
March 4, 2011
Devine EB, Hansen RN, Wilson-Norton JL, et al. The impact of computerized provider order entry on
medication errors in a multispecialty group practice. J Am Med Inform Assoc. 2010;17(1):78-84.
doi…
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psnet.ahrq.gov/node/46956/psn-pdf
January 23, 2019 - Impact of a national QI programme on reducing electronic
health record notifications to clinicians.
January 23, 2019
Shah T, Patel-Teague S, Kroupa L, et al. Impact of a national QI programme on reducing electronic health
record notifications to clinicians. BMJ Qual Saf. 2018;28(1):10-14. doi:10.1136/bmjqs-2017-007…
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - SPOTLIGHT CASE
What Happened on Telemetry?
Citation Text:
Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNo…
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - The Impact of Communication on Medication Errors
March 15, 2021
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors
The Case
A 93-year-old man with a history of chronic systolic heart failure…
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psnet.ahrq.gov/node/49756/psn-pdf
April 01, 2016 - Lost in Sign Out and Documentation
April 1, 2016
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
The Case
A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the
emergency physician, …
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psnet.ahrq.gov/node/49479/psn-pdf
April 01, 2005 - The Forgotten Med
April 1, 2005
Cucina R. The Forgotten Med. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/forgotten-med
The Case
A 78-year-old woman with a history of chronic obstructive pulmonary disease (COPD) came to the hospital
with increasing shortness of breath and chest pain. Although she had no …
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psnet.ahrq.gov/node/33582/psn-pdf
September 15, 2024 - Detection of Safety Hazards
September 15, 2024
Detection of Safety Hazards. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/detection-safety-hazards
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient s…
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psnet.ahrq.gov/primer/detection-safety-hazards
March 30, 2022 - Detection of Safety Hazards
Citation Text:
Detection of Safety Hazards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…
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psnet.ahrq.gov/node/33856/psn-pdf
April 01, 2018 - Patient Safety During Hospital Discharge
April 1, 2018
Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
Perspective
Patients are admitted to the hospital in the United States 35 million times per year.(1)…
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psnet.ahrq.gov/web-mm/nstemi-curbside-consultation
August 04, 2021 - SPOTLIGHT CASE
The NSTEMI Curbside Consultation
Citation Text:
Villablanca AC, Wong GX. The NSTEMI Curbside Consultation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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