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  1. psnet.ahrq.gov/issue/development-medical-checklists-improved-quality-patient-care
    March 23, 2011 - Review Development of medical checklists for improved quality of patient care. Citation Text: Hales B, Terblanche M, Fowler R, et al. Development of medical checklists for improved quality of patient care. International Journal for Quality in Health Care. 2007;20(1). doi:10.1093/intqhc…
  2. psnet.ahrq.gov/issue/effects-intervention-increase-bed-alarm-use-prevent-falls-hospitalized-patients-cluster
    January 03, 2017 - Study Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial. Citation Text: Shorr RI, Chandler M, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a clust…
  3. psnet.ahrq.gov/issue/correlation-between-hospital-rating-agencies-data-analysis-and-recommendation
    April 05, 2023 - Study Correlation between hospital rating agencies' data: an analysis and recommendation. Citation Text: Sondheim SE, Mattie A, Vigil J, et al. Correlation between hospital rating agencies’ data: An analysis and recommendation. J Healthc Risk Manag. 2020;40(3):18-24. doi:10.1002/jhrm.214…
  4. psnet.ahrq.gov/issue/description-and-factors-associated-missed-nursing-care-acute-care-community-hospital
    August 15, 2012 - Study Emerging Classic Description and factors associated with missed nursing care in an acute care community hospital. Citation Text: Duffy JR, Culp S, Padrutt T. Description and factors associated with missed nursing care in an acute care community hospital. J…
  5. psnet.ahrq.gov/issue/ashp-national-survey-pharmacy-practice-hospital-settings-dispensing-and-administration-2017
    September 30, 2020 - Study ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2017. Citation Text: Schneider PJ, Pedersen CA, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration-2017. Am J Health Syst Pharm.…
  6. psnet.ahrq.gov/issue/interventions-reduction-prescribed-opioid-use-chronic-non-cancer-pain
    April 04, 2011 - Review Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. Citation Text: Eccleston C, Fisher E, Thomas KH, et al. Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. Cochrane Database Syst Rev. 2017;11:CD010323. doi:10.10…
  7. psnet.ahrq.gov/issue/evidence-base-us-joint-commission-hospital-accreditation-standards-cross-sectional-study
    June 09, 2021 - Study The evidence base for US Joint Commission hospital accreditation standards: cross sectional study. Citation Text: Ibrahim SA, Reynolds KA, Poon E, et al. The evidence base for US joint commission hospital accreditation standards: cross sectional study. BMJ. 2022;377:e063064. doi:10…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49871/psn-pdf
    August 10, 2019 - Renal Failure Due to Benign Prostatic Hyperplasia August 10, 2019 Barry MJ, Garnick MB. Renal Failure Due to Benign Prostatic Hyperplasia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/renal-failure-due-benign-prostatic-hyperplasia The Case A 65-year-old man was referred to urology for a 5-year history of …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857260/psn-pdf
    November 30, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! November 30, 2023 Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/when…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49544/psn-pdf
    September 01, 2007 - Discharging Our Responsibility September 1, 2007 Fonarow GC. Discharging Our Responsibility. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/discharging-our-responsibility The Case A 75-year-old man with a history of hypertension, coronary artery disease, and congestive heart failure (CHF) presented to the …
  11. psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
    September 27, 2023 - The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. Citation Text: Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depa…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49415/psn-pdf
    September 01, 2003 - Intubation Mishap September 1, 2003 Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/intubation-mishap Case Objectives To understand and apply a structured method of human factors case analysis To describe the key components of effective teamwork To understand the imp…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72520/psn-pdf
    January 01, 2021 - Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion. December 2, 2020 Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion. JAMA Surg. 2021;156(1):76. doi:10.1001/jamasu…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38260/psn-pdf
    April 22, 2011 - Information exchange among physicians caring for the same patient in the community. April 22, 2011 van Walraven C, Taljaard M, Bell CM, et al. Information exchange among physicians caring for the same patient in the community. CMAJ. 2008;179(10):1013-8. doi:10.1503/cmaj.080430. https://psnet.ahrq.gov/issue/informa…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34669/psn-pdf
    June 26, 2015 - Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error. June 26, 2015 Edmondson AC. Learning from Mistakes is Easier Said Than Done: Group and Organizational Influences on the Detection and Correction of Human Error. J Appl Behav Sci. 200…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47529/psn-pdf
    January 21, 2019 - Community-acquired and hospital-acquired medication harm among older inpatients and impact of a state-wide medication management intervention. January 21, 2019 Pellegrin K, Lozano A, Miyamura J, et al. Community-acquired and hospital-acquired medication harm among older inpatients and impact of a state-wide medica…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39655/psn-pdf
    July 07, 2010 - Errors of diagnosis in pediatric practice: a multisite survey. July 7, 2010 Singh H, Thomas EJ, Wilson L, et al. Errors of diagnosis in pediatric practice: a multisite survey. Pediatrics. 2010;126(1):70-9. doi:10.1542/peds.2009-3218. https://psnet.ahrq.gov/issue/errors-diagnosis-pediatric-practice-multisite-survey…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60635/psn-pdf
    January 01, 2021 - Systemic defenses to prevent intravenous medication errors in hospitals: a systematic review. July 1, 2020 Kuitunen SK, Niittynen I, Airaksinen M, et al. Systemic Defenses to Prevent Intravenous Medication Errors in Hospitals. J Patient Saf. 2021;17(8):e1669-e1680. doi:10.1097/pts.0000000000000688. https://psnet.a…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42515/psn-pdf
    October 24, 2013 - Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws. October 24, 2013 Taylor AM, Chuo J, Figueroa-Altmann A, et al. Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws. Jt Comm J Qual Patient Saf. 2013;39(9):396-403. https://psnet.ahrq.g…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36150/psn-pdf
    September 29, 2010 - Nurse-physician communication during labor and birth: implications for patient safety. September 29, 2010 Simpson KR, James DC, Knox E. Nurse-physician communication during labor and birth: implications for patient safety. J Obstet Gynecol Neonatal Nurs. 2006;35(4):547-56. https://psnet.ahrq.gov/issue/nurse-physic…

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