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psnet.ahrq.gov/node/45759/psn-pdf
July 11, 2017 - Association between end-of-rotation resident transition in
care and mortality among hospitalized patients.
July 11, 2017
Denson JL, Jensen A, Saag HS, et al. Association Between End-of-Rotation Resident Transition in Care
and Mortality Among Hospitalized Patients. JAMA. 2016;316(21):2204-2213.
doi:10.1001/jama.201…
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psnet.ahrq.gov/node/38706/psn-pdf
June 17, 2009 - Experience with a trigger tool for identifying adverse drug
events among older adults in ambulatory primary care.
June 17, 2009
Singh R, McLean-Plunckett EA, Kee R, et al. Experience with a trigger tool for identifying adverse drug
events among older adults in ambulatory primary care. Qual Saf Health Care. 2009;18(…
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psnet.ahrq.gov/node/840259/psn-pdf
November 16, 2022 - Clinician collaboration to improve clinical decision
support: the Clickbusters initiative.
November 16, 2022
Mc Coy AB, Russo EM, Johnson KB, et al. Clinician collaboration to improve clinical decision support: the
Clickbusters initiative. J Am Med Inform Assoc. Epub 2022 Mar 4
https://psnet.ahrq.gov/innovation/cl…
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psnet.ahrq.gov/node/39501/psn-pdf
January 03, 2017 - Harmful medication errors involving unfractionated and
low-molecular-weight heparin in three patient safety
reporting programs.
January 3, 2017
Grissinger MC, Hicks RW, Keroack MA, et al. Harmful medication errors involving unfractionated and low-
molecular-weight heparin in three patient safety reporting programs…
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psnet.ahrq.gov/node/45183/psn-pdf
July 20, 2016 - Assessing the relationship between patient safety culture
and EHR strategy.
July 20, 2016
Ford E, Silvera GA, Kazley AS, et al. Assessing the relationship between patient safety culture and EHR
strategy. Int J Health Care Qual Assur. 2016;29(6):614-27. doi:10.1108/IJHCQA-10-2015-0125.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/47267/psn-pdf
September 05, 2018 - The national cost of adverse drug events resulting from
inappropriate medication-related alert overrides in the
United States.
September 5, 2018
Slight SP, Seger DL, Franz C, et al. The national cost of adverse drug events resulting from inappropriate
medication-related alert overrides in the United States. J Am M…
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psnet.ahrq.gov/issue/quality-and-safety
January 08, 2020 - Multi-use Website
Quality and Safety.
Citation Text:
Quality and Safety. Florida Hospital Association.
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psnet.ahrq.gov/issue/ihi-announces-hospitals-participating-100000-lives-campaign-have-saved-estimated-122300-lives
August 07, 2024 - Press Release/Announcement
Classic
IHI announces that hospitals participating in 100,000 Lives Campaign have saved an estimated 122,300 lives.
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psnet.ahrq.gov/node/43712/psn-pdf
December 03, 2014 - How context affects electronic health record–based test
result follow-up: a mixed-methods evaluation.
December 3, 2014
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):e005985. doi:10.1136/bmjopen-2014-00…
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psnet.ahrq.gov/node/40707/psn-pdf
March 11, 2013 - More than words: patients' views on apology and
disclosure when things go wrong in cancer care.
March 11, 2013
Mazor KM, Greene SM, Roblin DW, et al. More than words: patients' views on apology and disclosure
when things go wrong in cancer care. Patient Educ Couns. 2013;90(3):341-346.
doi:10.1016/j.pec.2011.07.010…
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-5
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR.
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psnet.ahrq.gov/issue/community-acquired-pneumonia-clinical-decision-support-implementation-toolkit
June 12, 2024 - Toolkit
Community-Acquired Pneumonia Clinical Decision Support Implementation Toolkit.
Citation Text:
Agency for Healthcare Research and Quality. Community-Acquired Pneumonia Clinical Decision Support Implementation Toolkit.
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psnet.ahrq.gov/issue/medication-safety-program
November 30, 2023 - Multi-use Website
Medication Safety Program.
Citation Text:
Medication Safety Program. Atlanta, GA: Centers for Disease Control and Prevention.
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psnet.ahrq.gov/issue/preventing-adverse-events-caused-emergency-electrical-power-system-failures
July 31, 2023 - Sentinel Event Alerts
Preventing adverse events caused by emergency electrical power system failures.
Citation Text:
Preventing adverse events caused by emergency electrical power system failures. Sentinel Event Alert. 2006;37(37):1-3.
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psnet.ahrq.gov/node/45036/psn-pdf
February 15, 2017 - Adverse Events in Rehabilitation Hospitals: National
Incidence Among Medicare Beneficiaries.
February 15, 2017
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector
General; July 2016. Report No. OEI-06-14-00110.
https://psnet.ahrq.gov/issue/adverse-events-rehabilitation-…
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psnet.ahrq.gov/issue/future-patient-and-family-engagement-quality-and-patient-safety
February 24, 2025 - Special or Theme Issue
The Future of Patient and Family Engagement in Quality and Patient Safety.
Citation Text:
The Future of Patient and Family Engagement in Quality and Patient Safety. Front Health Serv. 2024.
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psnet.ahrq.gov/issue/strong-surgery
October 15, 2018 - Multi-use Website
Strong for Surgery.
Citation Text:
Strong for Surgery. American College of Surgeons.
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psnet.ahrq.gov/issue/lives-and-dollars-lost-calculator
June 21, 2023 - Measurement Tool/Indicator
Lives and Dollars Lost Calculator.
Citation Text:
Lives and Dollars Lost Calculator. Leapfrog Group.
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psnet.ahrq.gov/issue/ihinpsf-lucian-leape-institute
July 12, 2017 - Multi-use Website
IHI Lucian Leape Institute.
Citation Text:
IHI Lucian Leape Institute. Institute for Healthcare Improvement.
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psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
April 01, 2008 - SPOTLIGHT CASE
A "Reflexive" Diagnosis in Primary Care
Citation Text:
Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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