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psnet.ahrq.gov/node/855091/psn-pdf
November 08, 2023 - Handoff tool improves transitions from the operating
room to the neonatal intensive care unit.
November 8, 2023
Gallois JB, Zagory JA, Barkemeyer B, et al. Handoff tool improves transitions from the operating room to
the neonatal intensive care unit. Pediatr Qual Saf. 2023;8(5):e695. doi:10.1097/pq9.000000000000069…
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psnet.ahrq.gov/node/41322/psn-pdf
November 27, 2012 - Errors of medical interpretation and their potential clinical
consequences: a comparison of professional versus ad
hoc versus no interpreters.
November 27, 2012
Flores G, Abreu M, Barone CP, et al. Errors of medical interpretation and their potential clinical
consequences: a comparison of professional versus ad ho…
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psnet.ahrq.gov/node/45436/psn-pdf
August 31, 2016 - Improving the communication between teams managing
boarded patients on a surgical specialty ward.
August 31, 2016
Puvaneswaralingam S, Ross D. Improving the communication between teams managing boarded patients
on a surgical specialty ward. BMJ Qual Improv Rep. 2016;5(1). doi:10.1136/bmjquality.u209186.w3750.
http…
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psnet.ahrq.gov/node/850173/psn-pdf
June 07, 2023 - A national safety board made transportation safer and
could do the same for health care, advocates say.
June 7, 2023
Jaklevic MC. CNN. May 30, 2023.
https://psnet.ahrq.gov/issue/national-safety-board-made-transportation-safer-and-could-do-same-health-
care-advocates-say
Patient safety has long drawn from aviation…
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psnet.ahrq.gov/node/35297/psn-pdf
February 10, 2011 - A computer alert system to prevent injury from adverse
drug events: development and evaluation in a community
teaching hospital.
February 10, 2011
Raschke RA, Gollihare B, Wunderlich TA, et al. A Computer Alert System to Prevent Injury From Adverse
Drug Events. JAMA. 2003;280(15). doi:10.1001/jama.280.15.1317.
ht…
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psnet.ahrq.gov/node/45108/psn-pdf
October 11, 2017 - IT-CARES: an interactive tool for case-crossover analyses
of electronic medical records for patient safety.
October 11, 2017
Caron A, Chazard E, Muller J, et al. IT-CARES: an interactive tool for case-crossover analyses of electronic
medical records for patient safety. J Am Med Inform Assoc. 2017;24(2):323-330.
do…
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psnet.ahrq.gov/node/45123/psn-pdf
May 07, 2018 - Hardwiring safety into the computer system: one
hospital's actions to provide technology support for U-
500 insulin.
May 7, 2018
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2016;21:1-4.
https://psnet.ahrq.gov/issue/hardwiring-safety-computer-system-one-hospitals-actions-provide-technology-
support-u-…
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psnet.ahrq.gov/node/73165/psn-pdf
April 21, 2021 - Recommendations for the safe, effective use of adaptive
CDS in the US healthcare system: an AMIA position
paper.
April 21, 2021
Petersen C, Smith J, Freimuth RR, et al. Recommendations for the safe, effective use of adaptive CDS in
the US healthcare system: an AMIA position paper. J Amer Med Inform Assoc. 2020;28(…
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psnet.ahrq.gov/node/73166/psn-pdf
April 21, 2021 - Trust and medical AI: the challenges we face and the
expertise needed to overcome them.
April 21, 2021
Quinn TP, Senadeera M, Jacobs S, et al. Trust and medical AI: the challenges we face and the expertise
needed to overcome them. J Amer Med Inform Assoc. 2021;28(4):890-894. doi:10.1093/jamia/ocaa268.
https://psne…
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psnet.ahrq.gov/node/847539/psn-pdf
April 12, 2023 - Potential uses of AI for perioperative nursing handoffs: a
qualitative study.
April 12, 2023
King CR, Shambe A, Abraham J. Potential uses of AI for perioperative nursing handoffs: a qualitative
study. JAMIA Open. 2023;6(1):ooaf015. doi:10.1093/jamiaopen/ooad015.
https://psnet.ahrq.gov/issue/potential-uses-ai-perio…
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psnet.ahrq.gov/node/851065/psn-pdf
June 28, 2023 - Patient safety of perioperative medication through the
lens of digital health and artificial intelligence.
June 28, 2023
Ye J. Patient safety of perioperative medication through the lens of digital health and artificial intelligence.
JMIR Periop Med. 2023;6:e34453. doi:10.2196/34453.
https://psnet.ahrq.gov/issue/p…
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psnet.ahrq.gov/node/36476/psn-pdf
December 14, 2009 - 10 Patient Safety Tips for Hospitals.
December 14, 2009
Rockville, MD: Agency for Healthcare Research and Quality; December 2009. AHRQ Publication No. 10-
M008.
https://psnet.ahrq.gov/issue/10-patient-safety-tips-hospitals
This tip sheet provides 10 practical steps hospitals can undertake to improve patient safety…
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psnet.ahrq.gov/node/46589/psn-pdf
April 12, 2019 - Patient perceptions of receiving test results via online
portals: a mixed-methods study.
April 12, 2019
Giardina TD, Baldwin J, Nystrom DT, et al. Patient perceptions of receiving test results via online portals: a
mixed-methods study. J Am Med Inform Assoc. 2018;25(4):440-446. doi:10.1093/jamia/ocx140.
https://ps…
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psnet.ahrq.gov/node/45505/psn-pdf
July 01, 2017 - A model for the departmental quality management
infrastructure within an academic health system.
July 1, 2017
Mathews SC, Demski R, Hooper JE, et al. A Model for the Departmental Quality Management
Infrastructure Within an Academic Health System. Acad Med. 2017;92(5):608-613.
doi:10.1097/ACM.0000000000001380.
htt…
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psnet.ahrq.gov/node/44134/psn-pdf
November 06, 2015 - Understanding missed opportunities for more timely
diagnosis of cancer in symptomatic patients after
presentation.
November 6, 2015
Lyratzopoulos G, Vedsted P, Singh H. Understanding missed opportunities for more timely diagnosis of
cancer in symptomatic patients after presentation. Br J Cancer. 2015;112 Suppl 1:S…
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psnet.ahrq.gov/node/73700/psn-pdf
September 15, 2021 - Preliminary study of patient safety and quality use cases
for ICD-11 MMS.
September 15, 2021
Fenton SH, Giannangelo KL, Stanfill MH. Preliminary study of patient safety and quality use cases for ICD-
11 MMS. J Am Med Inform Assoc. 2021;28(11):2346-2353. doi:10.1093/jamia/ocab163.
https://psnet.ahrq.gov/issue/preli…
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psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
May 16, 2022 - Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital
Citation Text:
Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…
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psnet.ahrq.gov/web-mm/suicidal-man-gun
May 01, 2005 - Suicidal Man With Gun
Citation Text:
Simon RI. Suicidal Man With Gun. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
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psnet.ahrq.gov/node/33691/psn-pdf
December 01, 2009 - How to Identify and Manage Problem Behaviors
December 1, 2009
Rosenstein AH, O'Daniel M. How to Identify and Manage Problem Behaviors. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
Perspective
The 1999 Institute of Medicine report highlighted the need for heal…
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psnet.ahrq.gov/node/49495/psn-pdf
December 01, 2005 - Low on the Totem Pole
December 1, 2005
Wachter R. Low on the Totem Pole. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/low-totem-pole
Case Objectives
Understand the concept of authority gradient
List steps that can be taken to increase communication across an authority gradient
Consider the current cultu…