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psnet.ahrq.gov/node/837663/psn-pdf
July 13, 2022 - Long-term risk of overdose or mental health crisis after
opioid dose tapering.
July 13, 2022
Fenton JJ, Magnan E, Tseregounis IE, et al. Long-term risk of overdose or mental health crisis after opioid
dose tapering. JAMA Netw Open. 2022;5(6):e2216726. doi:10.1001/jamanetworkopen.2022.16726.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/47846/psn-pdf
March 06, 2019 - Assessment of the FDA Risk Evaluation and Mitigation
Strategy for transmucosal immediate-release fentanyl
products.
March 6, 2019
Rollman JE, Heyward J, Olson L, et al. Assessment of the FDA Risk Evaluation and Mitigation Strategy for
Transmucosal Immediate-Release Fentanyl Products. JAMA. 2019;321(7):676-685.
do…
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psnet.ahrq.gov/node/34707/psn-pdf
September 29, 2017 - National Patient Safety Foundation agenda for research
and development in patient safety.
September 29, 2017
Cooper JB, Gaba DM, Liang B, et al. The National Patient Safety Foundation agenda for research and
development in patient safety. MedGenMed. 2000;2(3):E38.
https://psnet.ahrq.gov/issue/national-patient-safe…
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psnet.ahrq.gov/node/60297/psn-pdf
January 01, 2021 - A call for the application of patient safety culture in
medical humanitarian action: a literature review.
May 6, 2020
Biquet J-M, Schopper D, Sprumont D, et al. A call for the application of patient safety culture in medical
humanitarian action: a literature review. J Patient Saf. 2021;17(8):e1732-e1737.
doi:10.10…
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psnet.ahrq.gov/node/836998/psn-pdf
April 27, 2022 - How will state medical boards handle cases involving
disclosure and apology for medical errors?
April 27, 2022
Wojcieszak D. How will state medical boards handle cases involving disclosure and apology for medical
errors? J Patient Saf Risk Manag. 2022;27(1):15-20. doi:10.1177/25160435211070096.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/41245/psn-pdf
March 29, 2012 - The occurrence of wrong-site surgery self-reported by
candidates for certification by the American Board of
Orthopaedic Surgery.
March 29, 2012
James MA, Seiler JG, Harrast JJ, et al. The occurrence of wrong-site surgery self-reported by candidates
for certification by the American Board of Orthopaedic Surgery. J …
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psnet.ahrq.gov/node/47385/psn-pdf
April 27, 2019 - Reasons for repeat rapid response team calls, and
associations with in-hospital mortality.
April 27, 2019
Chalwin R, Giles L, Salter A, et al. Reasons for Repeat Rapid Response Team Calls, and Associations with
In-Hospital Mortality. Jt Comm J Qual Patient Saf. 2019;45(4):268-275. doi:10.1016/j.jcjq.2018.10.005.
h…
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psnet.ahrq.gov/node/865920/psn-pdf
May 22, 2024 - Role of knowledge and reasoning processes as
predictors of resident physicians' susceptibility to
anchoring bias in diagnostic reasoning: a randomised
controlled experiment.
May 22, 2024
Mamede S, Zandbergen A, de Carvalho-Filho MA, et al. Role of knowledge and reasoning processes as
predictors of resident physic…
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psnet.ahrq.gov/node/39872/psn-pdf
February 25, 2013 - The Essential Guide for Patient Safety Officers, Second
Edition.
February 25, 2013
Leonard M, Frankel A, Federico F, et al, eds. Oakbrook Terrace, IL: Joint Commission Resources, Institute
for Healthcare Improvement; 2013. ISBN: 9781599407036.
https://psnet.ahrq.gov/issue/essential-guide-patient-safety-officers-se…
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psnet.ahrq.gov/node/866818/psn-pdf
September 25, 2024 - Academic half day improves resident perception of
education without compromising patient safety.
September 25, 2024
Spence MC, Sugarman A, Uong A, et al. Academic half day improves resident perception of education
without compromising patient safety. Acad Pediatr. 2024;24(6):1010-1016. doi:10.1016/j.acap.2024.02.00…
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psnet.ahrq.gov/node/60958/psn-pdf
September 30, 2020 - Characteristics and unexpected COVID-19 diagnoses in
resuscitation room patients during the COVID-19 outbreak
- a retrospective case series.
September 30, 2020
Bergrath S, Aretz O, Haake H, et al. Characteristics and unexpected COVID-19 diagnoses in resuscitation
room patients during the COVID-19 outbreak - a retr…
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psnet.ahrq.gov/node/45855/psn-pdf
March 15, 2017 - The development and implementation of cognitive aids
for critical events in pediatric anesthesia: the Society for
Pediatric Anesthesia Critical Events Checklists.
March 15, 2017
Clebone A, Burian BK, Watkins SC, et al. The Development and Implementation of Cognitive Aids for
Critical Events in Pediatric Anesthesia…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-pda.pdf
June 02, 2025 - NICU Family Information Packet, Appendix B, Patent Ductus Arteriosus
Patent Ductus Arteriosus
Characteristics
■ A persistent open connection beyond 3 months of age between the pulmonary artery and the
aorta with blood flow from the aorta to the pulmonary artery.
■ An open ductus may lead to:
– Congestive heart…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-weaning.pdf
June 02, 2025 - NICU Family Information Packet, Appendix B, Weaning
Weaning
Description
■ The introduction of solid food feedings and the gradual replacement of milk by solid food as
the main source of energy and nutrients.
■ Shared pleasure in eating and feeding enhances the relationship between infants and their
caregivers.
…
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psnet.ahrq.gov/node/38517/psn-pdf
February 17, 2011 - Use of electronic health records in US hospitals.
February 17, 2011
Jha AK, DesRoches CM, Campbell EG, et al. Use of electronic health records in U.S. hospitals.
doi:10.1056/NEJMsa0900592.
https://psnet.ahrq.gov/issue/use-electronic-health-records-us-hospitals
Increasing the use of electronic health records (EHRs)…
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psnet.ahrq.gov/node/47027/psn-pdf
June 19, 2018 - Overdiagnosis and overtreatment as a quality problem:
insights from healthcare improvement research.
June 19, 2018
Armstrong N. Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement
research. BMJ Qual Saf. 2018;27(7):571-575. doi:10.1136/bmjqs-2017-007571.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/47479/psn-pdf
December 12, 2018 - "Closing the loop": a mixed-methods study about
resident learning from outcome feedback after patient
handoffs.
December 12, 2018
Shenvi EC, Feupe SF, Yang H, et al. "Closing the loop": a mixed-methods study about resident learning
from outcome feedback after patient handoffs. Diagnosis (Berl). 2018;5(4):235-242. …
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psnet.ahrq.gov/node/47391/psn-pdf
September 12, 2018 - Improving diagnosis by improving education: a policy
brief on education in healthcare professions.
September 12, 2018
Graber ML, Rencic J, Rusz D, et al. Improving diagnosis by improving education: a policy brief on
education in healthcare professions. Diagnosis (Berl). 2018;5(3):107-118. doi:10.1515/dx-2018-0033.
…
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psnet.ahrq.gov/node/837027/psn-pdf
May 04, 2022 - Association of measured quality with financial health
among U.S. hospitals.
May 4, 2022
Enumah SJ, Resnick AS, Chang DC. Association of measured quality with financial health among U.S.
hospitals. PLOS ONE. 2022;17(4):e0266696. doi:10.1371/journal.pone.0266696.
https://psnet.ahrq.gov/issue/association-measured-qua…
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psnet.ahrq.gov/node/44104/psn-pdf
July 16, 2015 - Errors upstream and downstream to the Universal
Protocol associated with wrong surgery events in the
Veterans Health Administration.
July 16, 2015
Paull DE, Mazzia L, Neily J, et al. Errors upstream and downstream to the Universal Protocol associated
with wrong surgery events in the Veterans Health Administration.…