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psnet.ahrq.gov/issue/patient-observer-approach-alternative-method-hand-hygiene-auditing-ambulatory-care-setting
September 13, 2023 - Study
Patient-as-observer approach: an alternative method for hand hygiene auditing in an ambulatory care setting.
Citation Text:
Le-Abuyen S, Ng J, Kim S, et al. Patient-as-observer approach: an alternative method for hand hygiene auditing in an ambulatory care setting. Am J Infect Cont…
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psnet.ahrq.gov/issue/measurement-and-monitoring-safety-impact-and-challenges-putting-conceptual-framework-practice
January 24, 2018 - Study
Measurement and monitoring of safety: impact and challenges of putting a conceptual framework into practice.
Citation Text:
Chatburn E, Macrae C, Carthey J, et al. Measurement and monitoring of safety: impact and challenges of putting a conceptual framework into practice. BMJ Qual …
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psnet.ahrq.gov/issue/improving-care-safety-characterizing-task-interruptions-during-interactions-between
March 05, 2025 - Study
Improving care safety by characterizing task interruptions during interactions between healthcare professionals: an observational study.
Citation Text:
Teigné D, Cazet L, Birgand G, et al. Improving care safety by characterizing task interruptions during interactions between health…
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psnet.ahrq.gov/issue/association-state-opioid-duration-limits-postoperative-opioid-prescribing
April 18, 2019 - Study
Emerging Classic
Association of state opioid duration limits with postoperative opioid prescribing.
Citation Text:
Agarwal S, Bryan JD, Hu HM, et al. Association of State Opioid Duration Limits With Postoperative Opioid Prescribing. JAMA Netw Open. 2019;2(…
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psnet.ahrq.gov/issue/transition-planning-senior-surgeon-guidance-and-recommendations-society-surgical-chairs
August 14, 2019 - Commentary
Transition planning for the senior surgeon: guidance and recommendations from the Society of Surgical Chairs.
Citation Text:
Rosengart TK, Doherty G, Higgins R, et al. Transition Planning for the Senior Surgeon: Guidance and Recommendations From the Society of Surgical Chairs.…
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psnet.ahrq.gov/issue/racism-pain-medicine-we-can-and-should-do-more
December 15, 2008 - Commentary
Racism in pain medicine: we can and should do more.
Citation Text:
Strand NH, Mariano ER, Goree JH, et al. Racism in pain medicine: we can and should do more. Mayo Clin Proc. 2021;96(6):1394-1400. doi:10.1016/j.mayocp.2021.02.030.
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psnet.ahrq.gov/issue/role-computerized-physician-order-entry-systems-facilitating-medication-errors
February 18, 2011 - Study
Classic
Role of computerized physician order entry systems in facilitating medication errors.
Citation Text:
Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293(10):119…
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psnet.ahrq.gov/issue/web-application-involve-patients-medication-reconciliation-process-user-centered-usability
August 18, 2021 - Study
A web application to involve patients in the medication reconciliation process: a user-centered usability and usefulness study.
Citation Text:
Marien S, Legrand D, Ramdoyal R, et al. A web application to involve patients in the medication reconciliation process: a user-centered usa…
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psnet.ahrq.gov/issue/30-day-potentially-avoidable-readmissions-due-adverse-drug-events
June 14, 2017 - Study
30-day potentially avoidable readmissions due to adverse drug events.
Citation Text:
Dalleur O, Beeler PE, Schnipper JL, et al. 30-Day Potentially Avoidable Readmissions Due to Adverse Drug Events. J Patient Saf. 2021;17(5):e379-e386. doi:10.1097/pts.0000000000000346.
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psnet.ahrq.gov/issue/economic-impact-medication-error-systematic-review
November 04, 2020 - Review
Economic impact of medication error: a systematic review.
Citation Text:
Walsh EK, Hansen CR, Sahm LJ, et al. Economic impact of medication error: a systematic review. Pharmacoepidemiol Drug Saf. 2017;26(5):481-497. doi:10.1002/pds.4188.
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psnet.ahrq.gov/issue/chronic-pain-diagnoses-and-opioid-dispensings-among-insured-individuals-serious-mental
November 29, 2023 - Study
Chronic pain diagnoses and opioid dispensings among insured individuals with serious mental illness.
Citation Text:
Owen-Smith A, Stewart C, Sesay MM, et al. Chronic pain diagnoses and opioid dispensings among insured individuals with serious mental illness. BMC Psych. 2020;20(1):4…
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psnet.ahrq.gov/issue/medication-reconciliation-and-patient-safety-trauma-applicability-existing-strategies
September 23, 2020 - Review
Medication reconciliation and patient safety in trauma: Applicability of existing strategies.
Citation Text:
DeAntonio JH, Leichtle SW, Hobgood S, et al. Medication reconciliation and patient safety in trauma: Applicability of existing strategies. J Surg Res. 2019;246:482-489. doi…
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psnet.ahrq.gov/issue/using-machine-learning-or-deep-learning-models-hospital-setting-detect-inappropriate
January 17, 2024 - Review
Using machine learning or deep learning models in a hospital setting to detect inappropriate prescriptions: a systematic review.
Citation Text:
Johns E, Alkanj A, Beck M, et al. Using machine learning or deep learning models in a hospital setting to detect inappropriate prescripti…
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psnet.ahrq.gov/issue/why-things-bite-back-technology-and-revenge-unintended-consequences
March 20, 2019 - Book/Report
Classic
Why Things Bite Back: Technology and the Revenge of Unintended Consequences.
Citation Text:
Why Things Bite Back: Technology and the Revenge of Unintended Consequences. Tenner E. New York, NY: Knopf; 1996. ISBN: 0679425632.
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psnet.ahrq.gov/issue/measuring-rate-manual-transcription-error-outpatient-point-care-testing
August 20, 2018 - Study
Measuring the rate of manual transcription error in outpatient point-of-care testing.
Citation Text:
Mays JA, Mathias PC. Measuring the rate of manual transcription error in outpatient point-of-care testing. J Am Med Inform Assoc. 2019;26(3):269-272. doi:10.1093/jamia/ocy170.
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psnet.ahrq.gov/issue/impact-medicares-nonpayment-program-hospital-acquired-conditions
December 21, 2014 - Review
Impact of Medicare's nonpayment program on hospital-acquired conditions.
Citation Text:
Thirukumaran CP, Glance LG, Temkin-Greener H, et al. Impact of Medicare's Nonpayment Program on Hospital-acquired Conditions. Med Care. 2017;55(5):447-455. doi:10.1097/MLR.0000000000000680.
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psnet.ahrq.gov/curated-library/diagnostic-error
August 10, 2025 - The majority of the diagnostic errors resulted in some form of clinical impact, including short-term … Missed or delayed diagnoses accounted for 21% of 55,377 claims analyzed, and the majority of these cases … Investigators found that three groups of diagnoses accounted for the majority of closed claims and high-severity
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psnet.ahrq.gov/node/33798/psn-pdf
January 01, 2015 - ineffective strategy for preventing further patient safety mishaps, particularly
considering that the majority … The majority of respondents, in all groups,
endorsed punitive measures such as fines, suspensions, or
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - High-Risk Pregnancy Program links clinicians and
patients across the state with UAMS, where the vast majority … Pregnancy Program links patients and clinicians across the state with the medical center,
where the vast majority … The majority of
referrals continue to be managed locally, but patients with abnormal findings may be … access to consultations: Since the implementation of the High-Risk Pregnancy
Program in 2003, the vast majority … Renewing annually, the program contract dedicates
the majority of funding toward the telemedicine infrastructure
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psnet.ahrq.gov/node/33853/psn-pdf
March 01, 2018 - But it is
disappointing that in the majority of hospitals there has been no change, and some hospitals … A majority of nurses say that they and other staff feel like their mistakes are held against them
and … RW: The majority of nurses in hospitals are working with and through technology.