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  1. psnet.ahrq.gov/issue/health-care-associated-infections-meta-analysis-costs-and-financial-impact-us-health-care
    July 31, 2013 - Study Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. Citation Text: Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JA…
  2. psnet.ahrq.gov/issue/massive-open-online-course-mooc-learning-builds-capacity-and-improves-competence-patient
    October 14, 2020 - Study Massive open online course (MOOC) learning builds capacity and improves competence for patient safety among global learners: a prospective cohort study. Citation Text: Gleason KT, Commodore-Mensah Y, Wu AW, et al. Massive open online course (MOOC) learning builds capacity and impro…
  3. psnet.ahrq.gov/issue/171-billion-problem-annual-cost-measurable-medical-errors
    May 26, 2021 - Study Classic The $17.1 billion problem: the annual cost of measurable medical errors. Citation Text: Van Den Bos J, Rustagi K, Gray T, et al. The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors. Health Aff. 2011;30(4):596-603. doi:10.1377/hl…
  4. psnet.ahrq.gov/issue/missed-diagnosis-stroke-emergency-department-cross-sectional-analysis-large-population-based
    April 08, 2018 - Study Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Citation Text: Newman-Toker DE, Moy E, Valente E, et al. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-b…
  5. psnet.ahrq.gov/issue/symptom-disease-pair-analysis-diagnostic-error-spade-conceptual-framework-and-methodological
    October 23, 2019 - Review Classic Symptom–Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data. Citation Text: Liberman AL, Newman-Toker DE. Symptom-Disease Pair Analysis of D…
  6. psnet.ahrq.gov/issue/analysis-clinical-decision-support-system-malfunctions-case-series-and-survey
    April 29, 2018 - Study Analysis of clinical decision support system malfunctions: a case series and survey. Citation Text: Wright A, Hickman T-TT, McEvoy D, et al. Analysis of clinical decision support system malfunctions: a case series and survey. J Am Med Inform Assoc. 2016;23(6):1068-1076. doi:10.1093…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36216/psn-pdf
    August 03, 2012 - Hospital Medication Errors Commonplace. August 3, 2012 Berwick D; Lassman S; Bates D. National Public Radio. July 28, 2006. https://psnet.ahrq.gov/issue/hospital-medication-errors-commonplace This segment features Donald Berwick, David Bates, and other experts discussing the Institute of Medicine (IOM) report Prev…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42072/psn-pdf
    August 03, 2016 - Innovation in Perioperative Patient Safety. August 3, 2016 Miller DR, Merry AF, eds. Can J Anesth. 2013;60(2):7-220. https://psnet.ahrq.gov/issue/innovation-perioperative-patient-safety Articles in this special issue discuss strategies to improve safety in anesthesia, including simulation training, perioperative c…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38233/psn-pdf
    March 03, 2010 - The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise. March 3, 2010 Kaji AH, Cone DC, eds. Acad Emerg Med. 2008;15:971-1222.   https://psnet.ahrq.gov/issue/science-simulation-healthcare-defining-and-developing-clinical-expertise This special issue highlights an AHRQ-funded sympo…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34016/psn-pdf
    July 03, 2013 - Profiles in patient safety: authority gradients in medical error. July 3, 2013 Cosby K, Croskerry P. Profiles in patient safety: authority gradients in medical error. Acad Emerg Med. 2004;11(12):1341-5. https://psnet.ahrq.gov/issue/profiles-patient-safety-authority-gradients-medical-error The authors apply the av…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40086/psn-pdf
    December 15, 2010 - The Safe Use Initiative and Health Literacy: Workshop Summary. December 15, 2010 Vancheri C; Roundtable on Health Literacy; Institute of Medicine. Washington, DC: National Academies Press; 2010. ISBN-10: 0309159318. https://psnet.ahrq.gov/issue/safe-use-initiative-and-health-literacy-workshop-summary This publica…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42756/psn-pdf
    November 20, 2013 - Removing the "me" from "MD." November 20, 2013 Parikh RB. Removing the “Me” From “MD”. JAMA. 2013;310(18). doi:10.1001/jama.2013.280722. https://psnet.ahrq.gov/issue/removing-me-md Recounting what one medical student learned by shadowing a nurse, this commentary emphasizes the importance of interprofessional commu…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35967/psn-pdf
    January 02, 2017 - Physician perception of hospital safety and barriers to incident reporting. January 2, 2017 Schectman JM, Plews-Ogan M. Physician perception of hospital safety and barriers to incident reporting. Jt Comm J Qual Patient Saf. 2006;32(6):337-43. https://psnet.ahrq.gov/issue/physician-perception-hospital-safety-and-ba…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34598/psn-pdf
    November 15, 2011 - Complexity and the Adoption of Innovation in Health Care. November 15, 2011 Plsek P. Washington DC: National Institute for Health Care Management Foundation and National Committee for Quality Health Care; 2003. https://psnet.ahrq.gov/issue/complexity-and-adoption-innovation-health-care In discussing the complexit…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33968/psn-pdf
    July 08, 2016 - Health Literacy: A Prescription to End Confusion. July 8, 2016 Nielsen-Bohlman L; Panzer AM; Kindig DA; Board on Neuroscience and Behavioral Health, Institute of Medicine. Washington, DC: The National Academies Press; 2004. ISBN: 9780309283328. https://psnet.ahrq.gov/issue/health-literacy-prescription-end-confusion…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42480/psn-pdf
    August 07, 2013 - A multi-tiered approach to safety education. August 7, 2013 Oates K, Sammut J, Kennedy P. A multi-tiered approach to safety education. Clin Teach. 2013;10(4):214- 8. doi:10.1111/tct.12037. https://psnet.ahrq.gov/issue/multi-tiered-approach-safety-education This commentary describes an initiative that incorporated …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35608/psn-pdf
    July 05, 2013 - Battling the obstetric malpractice crisis: improving patient safety, part 2. July 5, 2013 Bernstein PS. https://psnet.ahrq.gov/issue/battling-obstetric-malpractice-crisis-improving-patient-safety-part-2 This article addresses systems issues that need to be resolved in order to improve the safety of obstetric care…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39200/psn-pdf
    March 28, 2010 - Creating champions for health care quality and safety. March 28, 2010 Holland R, Meyers D, Hildebrand C, et al. Creating champions for health care quality and safety. Am J Med Qual. 2010;25(2):102-108. doi:10.1177/1062860609352108. https://psnet.ahrq.gov/issue/creating-champions-health-care-quality-and-safety Inte…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43035/psn-pdf
    October 12, 2018 - Patient's Toolkit for Diagnosis. October 12, 2018 SIDM Patient Engagement Committee. Evanston, IL: Society to Improve Diagnosis in Medicine; October 2018. https://psnet.ahrq.gov/issue/patients-toolkit-diagnosis Patient engagement has been promoted as a strategy to enhance safety in health care. This toolkit helps …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37642/psn-pdf
    March 26, 2008 - Medication, allergy, and adverse drug event discrepancies in ambulatory care. March 26, 2008 Stephens M, Fox B, Kukulka G, et al. Medication, allergy, and adverse drug event discrepancies in ambulatory care. Fam Med. 2008;40(2):107-10. https://psnet.ahrq.gov/issue/medication-allergy-and-adverse-drug-event-discrepa…

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