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psnet.ahrq.gov/issue/use-standard-design-medication-room-promote-medication-safety-organizational-implications
July 27, 2022 - Study
The use of a standard design medication room to promote medication safety: organizational implications.
Citation Text:
Rozenbaum H, Gordon L, Brezis M, et al. The use of a standard design medication room to promote medication safety: organizational implications. Int J Qual Health C…
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psnet.ahrq.gov/issue/error-codes-autopsy-study-potential-biases-diagnostic-error
November 30, 2012 - Study
Error codes at autopsy to study potential biases in diagnostic error.
Citation Text:
Goldman BI, Bharadwaj R, Fuller M, et al. Error codes at autopsy to study potential biases in diagnostic error. Diagnosis (Berl). 2023;10(4):375-382. doi:10.1515/dx-2023-0010.
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psnet.ahrq.gov/issue/promoting-effective-transitions-care-hospital-discharge-review-key-issues-hospitalists
November 16, 2022 - Review
Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists.
Citation Text:
Kripalani S, Jackson AT, Schnipper JL, et al. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. …
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psnet.ahrq.gov/issue/impact-non-interruptive-medication-laboratory-monitoring-alerts-ambulatory-care
March 10, 2011 - Study
Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care.
Citation Text:
Lo HG, Matheny ME, Seger DL, et al. Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care. J Am Med Inform Assoc. 2009;16(1):66-71. doi:10.1197/jami…
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psnet.ahrq.gov/issue/misdiagnosis-emergency-department-time-system-solution
March 25, 2020 - Commentary
Misdiagnosis in the emergency department: time for a system solution.
Citation Text:
Edlow JA, Pronovost PJ. Misdiagnosis in the emergency department: time for a system solution. JAMA. 2023;329(8):631-632. doi:10.1001/jama.2023.0577.
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DOI Goo…
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psnet.ahrq.gov/issue/misdiagnosis-mistreatment-and-harm-when-medical-care-ignores-social-forces
November 16, 2022 - Commentary
Emerging Classic
Misdiagnosis, mistreatment, and harm - when medical care ignores social forces.
Citation Text:
Holmes SM, Hansen H, Jenks A, et al. Misdiagnosis, mistreatment, and harm - when medical care ignores social forces. N Engl J Med. 2020;382…
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psnet.ahrq.gov/issue/effects-physical-environments-medical-wards-medication-communication-processes-affecting
November 17, 2021 - Study
The effects of physical environments in medical wards on medication communication processes affecting patient safety.
Citation Text:
Liu W, Manias E, Gerdtz M. The effects of physical environments in medical wards on medication communication processes affecting patient safety. Heal…
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psnet.ahrq.gov/issue/whos-covering-our-loved-ones-surprising-barriers-sign-out-process
October 19, 2022 - Study
Who's covering our loved ones: surprising barriers in the sign-out process.
Citation Text:
Antonoff MB, Berdan EA, Kirchner VA, et al. Who's covering our loved ones: surprising barriers in the sign-out process. Am J Surg. 2013;205(1):77-84. doi:10.1016/j.amjsurg.2012.05.009.
Co…
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psnet.ahrq.gov/issue/improving-quality-health-care-whats-taking-so-long
April 06, 2016 - Commentary
Classic
Improving the quality of health care: what's taking so long?
Citation Text:
Chassin MR. Improving The Quality Of Health Care: What’s Taking So Long? Health Aff. 2013;32(10):1761-1765. doi:10.1377/hlthaff.2013.0809.
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psnet.ahrq.gov/issue/learning-health-system-agenda-organizational-approaches-enhancing-occupational-well-being
October 28, 2020 - Commentary
A learning health system agenda for organizational approaches to enhancing occupational well-being among clinicians.
Citation Text:
Rotenstein LS, Melnick ER, Sinsky CA. A learning health system agenda for organizational approaches to enhancing occupational well-being among cl…
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psnet.ahrq.gov/issue/improving-diagnosis-feedback-and-deliberate-practice-one-one-coaching-diagnostic-maturation
July 06, 2022 - Study
Improving diagnosis by feedback and deliberate practice: one-on-one coaching for diagnostic maturation.
Citation Text:
Sinha P, Pischel L, Sofair AN. Improving diagnosis by feedback and deliberate practice: one-on-one coaching for diagnostic maturation. Diagnosis (Berl). 2021;8(2):…
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psnet.ahrq.gov/issue/diet-order-entry-registered-dietitians-results-reduction-error-rates-and-time-delays-compared
September 23, 2020 - Study
Diet order entry by registered dietitians results in a reduction in error rates and time delays compared with other health professionals.
Citation Text:
Imfeld K, Keith M, Stoyanoff L, et al. Diet order entry by registered dietitians results in a reduction in error rates and time …
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psnet.ahrq.gov/issue/context-matters-toward-multilevel-perspective-context-clinical-reasoning-and-error
April 12, 2023 - Commentary
Context matters: toward a multilevel perspective on context in clinical reasoning and error.
Citation Text:
Choi JJ, Durning SJ. Context matters: toward a multilevel perspective on context in clinical reasoning and error. Diagnosis (Berl). 2023;10(2):89-95. doi:10.1515/dx-2022…
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psnet.ahrq.gov/issue/five-years-after-err-human-what-have-we-learned
March 18, 2019 - Commentary
Classic
Five years after 'To Err is Human': what have we learned?
Citation Text:
Leape L, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. 2005;293(19):2384-90.
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psnet.ahrq.gov/issue/interrogating-and-uprooting-systemic-racism-emergency-department
March 05, 2025 - Commentary
Interrogating and uprooting systemic racism in the emergency department.
Citation Text:
Sangal RB, Khidir H, Agarwal AK. Interrogating and uprooting systemic racism in the emergency department. JAMA Health Forum. 2024;5(8):e242347. doi:10.1001/jamahealthforum.2024.2347.
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psnet.ahrq.gov/issue/closest-observers-patient-care-thematic-analysis-online-narrative-reviews-hospitals
December 12, 2014 - Study
From the closest observers of patient care: a thematic analysis of online narrative reviews of hospitals.
Citation Text:
Bardach N, Lyndon A, Asteria-Peñaloza R, et al. From the closest observers of patient care: a thematic analysis of online narrative reviews of hospitals. BMJ Qua…
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psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - A Seasonal Care Transition Failure
July 1, 2011
Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
The Case
A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine
resident—for routine follow-up…
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psnet.ahrq.gov/node/49823/psn-pdf
March 01, 2018 - Shortcuts to Acetaminophen-induced Liver Failure
March 1, 2018
Bacak S, Thornburg L. Shortcuts to Acetaminophen-induced Liver Failure. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure
The Case
An 18-year-old woman, 27 weeks pregnant, presented to the emergency dep…
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psnet.ahrq.gov/node/49736/psn-pdf
June 01, 2015 - Inflicting Confusion
June 1, 2015
Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/inflicting-confusion
The Case
A 26-year-old man with recently diagnosed Crohn disease presented to the emergency department with
acute-onset abdominal pain, nausea, vomiting, an…
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - Patient Safety 101
Citation Text:
Patient Safety 101. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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