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psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension
February 01, 2012 - Balancing Supervision and Autonomy: An Ongoing Tension
C. Jessica Dine, MD, MA; and Jennifer S. Myers, MD | February 1, 2012
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Dine JC, Myers JS. Balancing Supervision and Autonomy:…
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psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health
Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. In Conversation with Lucy Savitz about Learning Health Systems for
Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learnin…
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - SPOTLIGHT CASE
A Stroke of Error
Citation Text:
Barrett KM. A Stroke of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/838220/psn-pdf
September 27, 2019 - Primary Care and Patient Safety: Opportunities at the
Interface
September 28, 2022
O’Malley P, McNellis B, Chew E, et al. Primary Care and Patient Safety: Opportunities at the Interface.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
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psnet.ahrq.gov/issue/efficacy-tolerability-and-dose-dependent-effects-opioid-analgesics-low-back-pain-systematic
March 02, 2011 - Review
Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain: a systematic review and meta-analysis.
Citation Text:
Shaheed CA, Maher CG, Williams KA, et al. Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A S…
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psnet.ahrq.gov/issue/preventing-medication-errors-long-term-care-results-and-evaluation-large-scale-web-based
June 15, 2011 - Study
Preventing medication errors in long-term care: results and evaluation of a large scale web-based error reporting system.
Citation Text:
Pierson S, Hansen RA, Greene SB, et al. Preventing medication errors in long-term care: results and evaluation of a large scale web-based error…
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psnet.ahrq.gov/issue/outpatient-insulin-related-adverse-events-due-mix-errors-findings-two-national-surveillance
March 10, 2021 - Study
Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017.
Citation Text:
Geller AI, Conrad AO, Weidle NJ, et al. Outpatient insulin‐related adverse events due to mix‐up errors: Findings from two nation…
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psnet.ahrq.gov/issue/top-patient-safety-strategies-can-be-encouraged-adoption-now
September 20, 2011 - Commentary
The top patient safety strategies that can be encouraged for adoption now.
Citation Text:
Shekelle PG, Pronovost P, Wachter R, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013;158(5 Pt 2):365-8. doi:10.7326/0003-4819-158-…
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psnet.ahrq.gov/issue/impact-closed-loop-electronic-prescribing-and-administration-system-prescribing-errors
November 13, 2009 - Study
The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study.
Citation Text:
Franklin BD, O'Grady K, Donyai P, et al. The impact of a closed-loop electronic prescribing and admin…
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psnet.ahrq.gov/issue/barriers-and-motivators-making-error-reports-family-medicine-offices-report-american-academy
July 14, 2010 - Study
Barriers and motivators for making error reports from family medicine offices: a report from the American Academy of Family Physicians National Research Network (AAFP NRN).
Citation Text:
Elder NC, Graham D, Brandt E, et al. Barriers and motivators for making error reports from f…
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psnet.ahrq.gov/issue/private-patient-rooms-and-hospital-acquired-methicillin-resistant-staphylococcus-aureus
March 11, 2020 - Study
Private patient rooms and hospital-acquired methicillin-resistant Staphylococcus aureus: hospital-level analysis of administrative data from the United States.
Citation Text:
Park S-H, Stockbridge EL, Miller TL, et al. Private patient rooms and hospital-acquired methicillin-resista…
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psnet.ahrq.gov/issue/unscheduled-radiologic-examination-orders-electronic-health-record-novel-resource-targeting
March 30, 2022 - Study
Unscheduled radiologic examination orders in the electronic health record: a novel resource for targeting ambulatory diagnostic errors in radiology.
Citation Text:
Lacson R, Healey MJ, Cochon LR, et al. Unscheduled Radiologic Examination Orders in the Electronic Health Record: A No…
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psnet.ahrq.gov/issue/medication-related-clinical-decision-support-alert-overrides-inpatients
July 16, 2019 - Study
Medication-related clinical decision support alert overrides in inpatients.
Citation Text:
Nanji KC, Seger DL, Slight SP, et al. Medication-related clinical decision support alert overrides in inpatients. J Am Med Inform Assoc. 2018;25(5):476-481. doi:10.1093/jamia/ocx115.
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psnet.ahrq.gov/issue/descriptive-analysis-patient-misidentification-incident-report-system-data-large-academic
August 24, 2022 - Study
Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation.
Citation Text:
Abraham P, Augey L, Duclos A, et al. Descriptive analysis of patient misidentification from incident report system data in a large academic hos…
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psnet.ahrq.gov/issue/why-patient-summaries-electronic-health-records-do-not-provide-cognitive-support-necessary
January 18, 2013 - Study
Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.
Citation Text:
Staggers N, Clark L, Blaz JW, et al. Why patient summaries in electronic…
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psnet.ahrq.gov/issue/outcomes-associated-nationwide-introduction-rapid-response-systems-netherlands
January 18, 2013 - Study
Outcomes associated with the nationwide introduction of rapid response systems in the Netherlands.
Citation Text:
Ludikhuize J, Brunsveld-Reinders AH, Dijkgraaf MGW, et al. Outcomes Associated With the Nationwide Introduction of Rapid Response Systems in The Netherlands. Crit Care …
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psnet.ahrq.gov/issue/australian-hospital-leaders-provision-safe-care-implications-safety-i-and-safety-ii
August 18, 2021 - Study
Australian hospital leaders on the provision of safe care: implications for safety I and safety II.
Citation Text:
Leggat SG, Balding C, Bish M. Perspectives of Australian hospital leaders on the provision of safe care: implications for safety I and safety II. J Health Org Manag. 2…
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psnet.ahrq.gov/issue/going-covid-19-gemba-using-observation-and-high-reliability-strategies-achieve-safety-time
May 12, 2021 - Commentary
Going to the COVID-19 Gemba: using observation and high reliability strategies to achieve safety in a time of crisis.
Citation Text:
Thull-Freedman J, Mondoux S, Stang A, et al. Going to the COVID-19 Gemba: Using observation and high reliability strategies to achieve safety in…
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psnet.ahrq.gov/issue/patient-safety-emergency-departments-problem-health-care-systems-international-survey
February 26, 2020 - Study
Patient safety in emergency departments: a problem for health care systems? An international survey.
Citation Text:
Petrino R, Tuunainen E, Bruzzone G, et al. Patient safety in emergency departments: a problem for health care systems? An international survey. Eur J Emerg Med. 2023;…
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psnet.ahrq.gov/issue/impact-simulation-based-closed-loop-communication-training-medical-errors-pediatric-emergency
July 22, 2020 - Study
Impact of simulation-based closed-loop communication training on medical errors in a pediatric emergency department.
Citation Text:
Diaz MCG, Dawson K. Impact of Simulation-Based Closed-Loop Communication Training on Medical Errors in a Pediatric Emergency Department. Am J Med Qual…