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psnet.ahrq.gov/issue/quality-improvement-through-implementation-discharge-order-reconciliation
September 23, 2020 - Commentary
Quality improvement through implementation of discharge order reconciliation.
Citation Text:
Lu Y, Clifford P, Bjorneby A, et al. Quality improvement through implementation of discharge order reconciliation. Am J Health Syst Pharm. 2013;70(9):815-20. doi:10.2146/ajhp120050. …
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psnet.ahrq.gov/issue/how-should-medication-errors-be-defined-development-and-test-definition
June 27, 2011 - Study
How should medication errors be defined? Development and test of a definition.
Citation Text:
Lisby M, Nielsen LP, Brock B, et al. How should medication errors be defined? Development and test of a definition. Scand J Public Health. 2012;40(2):203-10. doi:10.1177/1403494811435489.…
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psnet.ahrq.gov/issue/why-it-so-hard-talk-about-overuse-pediatrics-and-why-it-matters
March 04, 2020 - Commentary
Why it is so hard to talk about overuse in pediatrics and why it matters.
Citation Text:
Ralston SL, Schroeder AR. Why It Is So Hard to Talk About Overuse in Pediatrics and Why It Matters. JAMA Pediatr. 2017;171(10):931-932. doi:10.1001/jamapediatrics.2017.2239.
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psnet.ahrq.gov/issue/nonhospital-health-care-associated-hepatitis-b-and-c-virus-transmission-united-states-1998
October 19, 2012 - Review
Nonhospital health care–associated hepatitis B and C virus transmission: United States, 1998-2008.
Citation Text:
Thompson ND, Perz JF, Moorman AC, et al. Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998-2008. Ann Intern Med. 2009;150(1)…
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psnet.ahrq.gov/issue/effect-computerized-physician-order-entry-radiologic-examination-order-indication-quality
June 13, 2015 - Study
Effect of computerized physician order entry on radiologic examination order indication quality.
Citation Text:
Schneider E, Franz W, Spitznagel R, et al. Effect of computerized physician order entry on radiologic examination order indication quality. Arch Intern Med. 2011;171(11…
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psnet.ahrq.gov/issue/systematic-review-performance-characteristics-clinical-event-monitor-signals-used-detect
March 28, 2012 - Review
A systematic review of the performance characteristics of clinical event monitor signals used to detect adverse drug events in the hospital setting.
Citation Text:
Handler S, Altman RL, Perera S, et al. A systematic review of the performance characteristics of clinical event mon…
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psnet.ahrq.gov/issue/see-one-sim-one-do-one-national-pre-internship-boot-camp-ensure-safer-student-doctor
February 16, 2011 - Study
"See One, Sim One, Do One"—a national pre-internship boot-camp to ensure a safer "student to doctor" transition.
Citation Text:
Minha S'ar, Shefet D, Sagi D, et al. "See One, Sim One, Do One"- A National Pre-Internship Boot-Camp to Ensure a Safer "Student to Doctor" Transition. PLo…
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psnet.ahrq.gov/issue/reconcilable-differences-correcting-medication-errors-hospital-admission-and-discharge
February 13, 2019 - Study
Reconcilable differences: correcting medication errors at hospital admission and discharge.
Citation Text:
Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care. 2006;15(2):122-6.
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psnet.ahrq.gov/issue/time-out-impact-physician-burnout-patient-care-quality-and-safety-perioperative-medicine
November 03, 2021 - Commentary
Time out: the impact of physician burnout on patient care quality and safety in perioperative medicine.
Citation Text:
Shin P, Desai V, Conte AH, et al. Time out: the impact of physician burnout on patient care quality and safety in perioperative medicine. Perm J. 2023;27(2):1…
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psnet.ahrq.gov/issue/look-alike-sound-alike-drugs-review-include-look-alike-packaging-additional-safety-check
March 24, 2021 - Study
Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check.
Citation Text:
McCoy LK. Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check. Jt Comm J Qual Patient Saf. 2005;31(1):47-53.
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psnet.ahrq.gov/issue/rapid-response-systems-identification-and-management-prearrest-state
May 18, 2022 - Review
Rapid response systems: identification and management of the "prearrest state."
Citation Text:
McCurdy MT, Wood SL. Rapid response systems: identification and management of the "prearrest state". Emerg Med Clin North Am. 2012;30(1):141-52. doi:10.1016/j.emc.2011.09.012.
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psnet.ahrq.gov/issue/innovative-use-electronic-health-record-support-harm-reduction-efforts
July 31, 2013 - Study
Innovative use of the electronic health record to support harm reduction efforts.
Citation Text:
Hyman D, Neiman J, Rannie M, et al. Innovative Use of the Electronic Health Record to Support Harm Reduction Efforts. Pediatrics. 2017;139(5). doi:10.1542/peds.2015-3410.
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psnet.ahrq.gov/issue/role-remediation-cases-serious-misconduct-uk-healthcare-regulators-qualitative-study
June 02, 2021 - Study
Role of remediation in cases of serious misconduct before UK healthcare regulators: a qualitative study.
Citation Text:
Price T, Reynolds E, O’Brien T, et al. Role of remediation in cases of serious misconduct before UK healthcare regulators: a qualitative study. BMJ Qual Saf. 2025…
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psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance
Measurement Tracking, and Performance Feedback
February 28, 2024
https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-
and-performance
Summary
To improve patient care and outcomes in the intensive care unit (ICU…
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - Personal Health Literacy
August 30, 2023
Bakerjian D. Personal Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/personal-health-literacy
Originally published in July 2017 by researchers at the University of California, San Francisco. Updated in
August 2023 by Deb Bakerjian, PhD, RN, APRN, FAA…
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psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
May 26, 2021 - SPOTLIGHT CASE
When the Indications for Drug Administration Blur
Citation Text:
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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…
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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging
July 8, 2022
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
The Cases
Case #1: A 42-year-old woman admitted with…
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psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
June 28, 2023 - patients with information about the newly prescribed medication and/or offering counseling at local pharmacies
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psnet.ahrq.gov/node/33579/psn-pdf
September 15, 2024 - Systems Approach
September 15, 2024
Systems Approach. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/systems-approach
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in …
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psnet.ahrq.gov/node/33601/psn-pdf
December 15, 2024 - Electronic Health Records
December 15, 2024
Electronic Health Records. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/electronic-health-records
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safet…