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  1. psnet.ahrq.gov/issue/effect-computerized-provider-order-entry-systems-clinical-care-and-work-processes-emergency
    May 25, 2011 - Review The effect of computerized provider order entry systems on clinical care and work processes in emergency departments: a systematic review of the quantitative literature. Citation Text: Georgiou A, Prgomet M, Paoloni R, et al. The effect of computerized provider order entry syst…
  2. psnet.ahrq.gov/issue/costs-intravenous-adverse-drug-events-academic-and-nonacademic-intensive-care-units
    August 11, 2021 - Study Costs of intravenous adverse drug events in academic and nonacademic intensive care units. Citation Text: Nuckols TK, Paddock SM, Bower AG, et al. Costs of intravenous adverse drug events in academic and nonacademic intensive care units. Med Care. 2009;46(1):17-24. doi:10.1097/m…
  3. psnet.ahrq.gov/issue/are-teaching-hospitals-treated-fairly-hospital-acquired-condition-reduction-program
    July 11, 2018 - Study Are teaching hospitals treated fairly in the Hospital-Acquired Condition Reduction Program? Citation Text: Mohajer MA, Joiner KA, Nix DE. Are Teaching Hospitals Treated Fairly in the Hospital-Acquired Condition Reduction Program? Acad Med. 2018;93(12):1827-1832. doi:10.1097/ACM.000…
  4. psnet.ahrq.gov/issue/assessment-health-information-technology-related-outpatient-diagnostic-delays-us-veterans
    June 24, 2020 - Study Assessment of health information technology-related outpatient diagnostic delays in the US Veterans Affairs health care system: a qualitative study of aggregated root cause analysis data. Citation Text: Powell L, Sittig DF, Chrouser K, et al. Assessment of health information techno…
  5. psnet.ahrq.gov/issue/physician-intent-pharmacy-label-prevalence-and-description-discrepancies-cross-sectional
    July 22, 2020 - Study From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions. Citation Text: Cochran GL, Klepser DG, Morien M, et al. From physician intent to the pharmacy label: prevalence and description o…
  6. psnet.ahrq.gov/issue/swarming-improve-patient-care-novel-approach-root-cause-analysis
    September 23, 2020 - Study "SWARMing" to improve patient care: a novel approach to root cause analysis. Citation Text: Li J, Boulanger B, Norton J, et al. "SWARMing" to Improve Patient Care: A Novel Approach to Root Cause Analysis. Jt Comm J Qual Patient Saf. 2015;41(11):494-501. Copy Citation Format: …
  7. psnet.ahrq.gov/issue/qualitative-study-speaking-out-about-patient-safety-concerns-intensive-care-units
    August 21, 2013 - Study A qualitative study of speaking out about patient safety concerns in intensive care units. Citation Text: Tarrant C, Leslie M, Bion J, et al. A qualitative study of speaking out about patient safety concerns in intensive care units. Soc Sci Med. 2017;193:8-15. doi:10.1016/j.socscim…
  8. psnet.ahrq.gov/issue/medication-errors-associated-code-situations-us-hospitals-direct-and-collateral-damage
    June 29, 2011 - Study Medication errors associated with code situations in U.S. hospitals: direct and collateral damage. Citation Text: Lipshutz AKM, Morlock LL, Shore AD, et al. Medication Errors Associated with Code Situations in U.S. Hospitals: Direct and Collateral Damage. Jt Comm J Qual Patient Saf…
  9. psnet.ahrq.gov/issue/hospital-acquired-functional-decline-and-clinical-outcomes-older-cardiac-surgical-patients
    February 06, 2019 - Study Hospital-acquired functional decline and clinical outcomes in older cardiac surgical patients: a multicenter prospective cohort study. Citation Text: Morisawa T, Saitoh M, Otsuka S, et al. Hospital-acquired functional decline and clinical outcomes in older cardiac surgical patients…
  10. psnet.ahrq.gov/issue/health-economic-evaluation-infection-prevention-and-control-program-are-quality-and-patient
    June 02, 2021 - Study Health economic evaluation of an infection prevention and control program: are quality and patient safety programs worth the investment? Citation Text: Raschka S, Dempster L, Bryce E. Health economic evaluation of an infection prevention and control program: are quality and patien…
  11. psnet.ahrq.gov/issue/association-surgical-task-during-training-team-skill-acquisition-among-surgical-residents
    March 12, 2025 - Study Association of a surgical task during training with team skill acquisition among surgical residents: the missing piece in multidisciplinary team training. Citation Text: Sparks JL, Crouch DL, Sobba K, et al. Association of a Surgical Task During Training With Team Skill Acquisition…
  12. psnet.ahrq.gov/issue/electronic-health-record-based-real-time-analytics-program-patient-safety-surveillance-and
    May 19, 2018 - Study An electronic health record–based real-time analytics program for patient safety surveillance and improvement. Citation Text: Classen D, Li M, Miller S, et al. An Electronic Health Record-Based Real-Time Analytics Program For Patient Safety Surveillance And Improvement. Health Aff …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43573/psn-pdf
    October 01, 2014 - Effective communication with primary care providers. October 1, 2014 Smith K. Effective communication with primary care providers. Pediatr Clin North Am. 2014;61(4):671-679. doi:10.1016/j.pcl.2014.04.004. https://psnet.ahrq.gov/issue/effective-communication-primary-care-providers Highlighting how the disconnect be…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865683/psn-pdf
    Our stubborn quest for diagnostic certainty. June 1, 1989 Kassirer JP. Our stubborn quest for diagnostic certainty. N Engl J Med. 1989;320(22):1489-1491. doi:10.1056/nejm198906013202211. https://psnet.ahrq.gov/issue/our-stubborn-quest-diagnostic-certainty The topic of uncertainty has been largely neglected in the …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45334/psn-pdf
    September 07, 2016 - Why 'Universal Precautions' are needed for medication lists. September 7, 2016 Shane R. Why 'Universal Precautions' are needed for medication lists. BMJ Qual Saf. 2016;25(9):731-2. doi:10.1136/bmjqs-2015-005116. https://psnet.ahrq.gov/issue/why-universal-precautions-are-needed-medication-lists Despite the support…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41373/psn-pdf
    May 16, 2012 - Self-reported violations during medication administration in two paediatric hospitals. May 16, 2012 Alper SJ, Holden RJ, Scanlon MC, et al. Self-reported violations during medication administration in two paediatric hospitals. BMJ Qual Saf. 2012;21(5):408-15. doi:10.1136/bmjqs-2011-000007. https://psnet.ahrq.gov/i…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45968/psn-pdf
    October 24, 2024 - State of Care. October 24, 2024 Newcastle Upon Tyne, UK: Care Quality Commission; October 2024. https://psnet.ahrq.gov/issue/state-care This website provides access to an annual report that summarizes National Health Service hospital and social care performance across a range of care quality metrics at both the tr…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853445/psn-pdf
    December 15, 2022 - Jake Tapper shares harrowing story of daughter's near- fatal misdiagnosis. December 15, 2022 CNN. December 15, 2022. https://psnet.ahrq.gov/issue/jake-tapper-shares-harrowing-story-daughters-near-fatal-misdiagnosis Diagnostic errors are a recognized cause of preventable patient harm.  This video highlights a teen’…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60538/psn-pdf
    May 27, 2020 - Diagnostic Safety Toolkit. May 27, 2020 Child Health Patient Safety Organization. Diagnostic Safety Toolkit. Washington DC: Children's Hospital Association. May 2020. https://psnet.ahrq.gov/issue/diagnostic-safety-toolkit Effective communication is an important component of diagnostic accuracy. Shaped with data co…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43734/psn-pdf
    January 21, 2015 - Explicit and Standardized Prescription Medicine Instructions. January 21, 2015 Rockville, MD: Agency for Healthcare Research and Quality; December 2014. https://psnet.ahrq.gov/issue/explicit-and-standardized-prescription-medicine-instructions Standardization has been embraced as a strategy to improve health litera…

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