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psnet.ahrq.gov/node/838078/psn-pdf
September 14, 2022 - Patient safety issues from information overload in
electronic medical records.
September 14, 2022
Nijor S, Rallis G, Lad N, et al. Patient safety issues from information overload in electronic medical records.
J Patient Saf. 2022;18(6):e999-e1003. doi:10.1097/pts.0000000000001002.
https://psnet.ahrq.gov/issue/pati…
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psnet.ahrq.gov/node/72854/psn-pdf
March 17, 2021 - Enabling sustained communication with patients for safe
and effective management of oral chemotherapy: a
longitudinal ethnography.
March 17, 2021
Mitchell G, Porter S, Manias E. Enabling sustained communication with patients for safe and effective
management of oral chemotherapy: a longitudinal ethnography. J Adv …
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psnet.ahrq.gov/node/46075/psn-pdf
May 03, 2017 - ED misdiagnosis of cerebrovascular events in the era of
modern neuroimaging: a meta-analysis.
May 3, 2017
Tarnutzer AA, Lee S-H, Robinson K, et al. ED misdiagnosis of cerebrovascular events in the era of modern
neuroimaging: A meta-analysis. Neurology. 2017;88(15):1468-1477.
doi:10.1212/WNL.0000000000003814.
http…
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide77.html
October 01, 2014 - 77. For the Patient Who Has Recently Quit (Continued)
Treating Tobacco Use and Dependence: 2008 Update
Text version of slide presentation.
Addressing problems encountered by former smokers (Continued)
Weight gain
Recommend starting or increasing physical activity.
Reassure the patient that…
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psnet.ahrq.gov/node/60693/psn-pdf
July 15, 2020 - Incoming interns recognize inadequate physical
examination as a cause of patient harm.
July 15, 2020
Russo S, Berg K, Davis JJ, et al. Incoming interns recognize inadequate physical examination as a cause
of patient harm. J Med Educ Curric Dev. 2020;7:238212052092899. doi:10.1177/2382120520928993.
https://psnet.ah…
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psnet.ahrq.gov/node/865718/psn-pdf
May 01, 2024 - Calculating the cost of medication errors: a systematic
review of approaches and cost variables.
May 1, 2024
Ranasinghe S, Nadeshkumar A, Senadheera S, et al. Calculating the cost of medication errors: a
systematic review of approaches and cost variables. BMJ Open Qual. 2024;13(2):e002570.
doi:10.1136/bmjoq-2023-0…
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psnet.ahrq.gov/node/842424/psn-pdf
January 11, 2023 - Unsafe by design: infusion task reallocation and safety
perceptions in U.S. hospitals.
January 11, 2023
Pratt BR, Dunford BB, Vogus TJ, et al. Unsafe by design: infusion task reallocation and safety perceptions
in U.S. hospitals. Health Care Manage Rev. 2022;48(1):14-22. doi:10.1097/hmr.0000000000000351.
https://p…
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psnet.ahrq.gov/node/73703/psn-pdf
September 15, 2021 - To expand the evidence base about harms from tests and
treatments.
September 15, 2021
Korenstein D, Harris RP, Elshaug AG, et al. To expand the evidence base about harms from tests and
treatments. J Gen Intern Med. 2021;36(7):2105-2110. doi:10.1007/s11606-021-06597-9.
https://psnet.ahrq.gov/issue/expand-evidence-b…
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psnet.ahrq.gov/node/846756/psn-pdf
March 29, 2023 - Frequency of medication administration timing error in
hospitals: a systematic review.
March 29, 2023
Pullam T, Russell CL, White-Lewis S. Frequency of medication administration timing error in hospitals: a
systematic review. J Nurs Care Qual. 2023;38(2):126-133. doi:10.1097/ncq.0000000000000668.
https://psnet.ahr…
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psnet.ahrq.gov/node/73612/psn-pdf
August 18, 2021 - Evaluating the impact of radio frequency identification
retained surgical instruments tracking on patient safety:
literature review.
August 18, 2021
Schnock KO, Biggs B, Fladger A, et al. Evaluating the impact of radio frequency identification retained
surgical instruments tracking on patient safety: literature re…
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psnet.ahrq.gov/node/47825/psn-pdf
March 06, 2019 - Diagnostic error as a result of drug-laboratory test
interactions.
March 6, 2019
van Balveren JA, van de Venne WPHGV-, Erdem-Eraslan L, et al. Diagnostic error as a result of drug-
laboratory test interactions. Diagnosis (Berl). 2019;6(1):69-71. doi:10.1515/dx-2018-0098.
https://psnet.ahrq.gov/issue/diagnostic-err…
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psnet.ahrq.gov/node/837065/psn-pdf
May 11, 2022 - Fast tracking in cardiac surgery: is it safe?
May 11, 2022
MacLeod JB, D’Souza K, Aguiar C, et al. Fast tracking in cardiac surgery: is it safe? J Cardiothorac Surg.
2022;17(1):69. doi:10.1186/s13019-022-01815-9.
https://psnet.ahrq.gov/issue/fast-tracking-cardiac-surgery-it-safe
Post-operative complications can le…
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psnet.ahrq.gov/node/74089/psn-pdf
July 15, 2002 - The effect of race and sex on physicians'
recommendations for cardiac catheterization.
July 15, 2002
Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians' recommendations for
cardiac catheterization. N Engl J Med. 2002;340(8):618-626. doi:10.1056/nejm199902253400806.
https://psnet.ahr…
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psnet.ahrq.gov/node/61075/psn-pdf
October 28, 2020 - FDA advises health care professionals and patients about
insulin pen packaging and dispensing.
October 28, 2020
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 13, 2020.
https://psnet.ahrq.gov/issue/fda-advises-health-care-professionals-and-patients-about-insulin-pen-
packag…
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psnet.ahrq.gov/node/50402/psn-pdf
October 02, 2019 - Improving Diagnostic Fidelity: An Approach to
Standardizing the Process in Patients With Emerging
Critical Illness
October 2, 2019
Jayaprakash N, Chae J, Sabov M, et al. Improving Diagnostic Fidelity: An Approach to Standardizing the
Process in Patients With Emerging Critical Illness. Mayo Clin Proc Innov Qual Out…
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psnet.ahrq.gov/node/39446/psn-pdf
May 25, 2010 - Worries and concerns experienced by nurse specialists
during inter-hospital transports of critically ill patients: a
critical incident study.
May 25, 2010
Gustafsson M, Wennerholm S, Fridlund B. Worries and concerns experienced by nurse specialists during
inter-hospital transports of critically ill patients: a cri…
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psnet.ahrq.gov/node/46304/psn-pdf
November 01, 2017 - Comparative performance of pediatric weight estimation
techniques: a human factor errors analysis.
November 1, 2017
Abdel-Rahman SM, Jacobsen R, Watts JL, et al. Comparative performance of pediatric weight estimation
techniques: a human factor errors analysis. Pediatr Emerg Care. 2015;33(8):548-552.
doi:10.1097/pe…
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psnet.ahrq.gov/node/866824/psn-pdf
September 25, 2024 - 'Failing wisely' can promote a safer healthcare system.
September 25, 2024
Fleisher LA, Edmondson AC. 'Failing wisely' can promote a safer healthcare system. MedPage Today.
September 17, 2024;
https://psnet.ahrq.gov/issue/failing-wisely-can-promote-safer-healthcare-system
The ability to learn-by-doing in an enviro…
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psnet.ahrq.gov/node/838187/psn-pdf
September 28, 2022 - Diagnostic delays in infectious diseases.
September 28, 2022
Suneja M, Beekmann SE, Dhaliwal G, et al. Diagnostic delays in infectious diseases. Diagnosis (Berl).
2022;9(3):332-339. doi:10.1515/dx-2021-0092.
https://psnet.ahrq.gov/issue/diagnostic-delays-infectious-diseases
Delayed diagnosis of infectious diseases…
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psnet.ahrq.gov/node/33993/psn-pdf
March 02, 2011 - Improving patient care. My right knee.
March 2, 2011
Berwick DM. Improving patient care. My right knee. Ann Intern Med. 2005;142(2):121-5.
https://psnet.ahrq.gov/issue/improving-patient-care-my-right-knee
Dr. Donald Berwick writes this compelling piece as a personal reflection on the current deficiencies in
health…