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psnet.ahrq.gov/node/35176/psn-pdf
June 23, 2009 - Mapping changes in surgical mortality over 9 years by
peer review audit.
June 23, 2009
Thompson A, Ashraf Z, Burton H, et al. Mapping changes in surgical mortality over 9 years by peer review
audit. Br J Surg. 2005;92(11):1449-52.
https://psnet.ahrq.gov/issue/mapping-changes-surgical-mortality-over-9-years-peer-re…
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psnet.ahrq.gov/node/47464/psn-pdf
October 17, 2018 - How to prevent the top 4 medication errors.
October 17, 2018
Sederstrom J. Drug Topics. September 17, 2018.
https://psnet.ahrq.gov/issue/how-prevent-top-4-medication-errors
Medication errors continue to be a worldwide patient safety challenge that requires both systems and
individual practice strategies for improv…
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psnet.ahrq.gov/node/35749/psn-pdf
May 09, 2014 - Chemotherapy dose limits set by users of a computer
order entry system.
May 9, 2014
DuBeshter B; Griggs J; Angel C; Loughner J.
https://psnet.ahrq.gov/issue/chemotherapy-dose-limits-set-users-computer-order-entry-system
To avoid excessive dosing of chemotherapeutic agents, standardized dose limits must be agreed u…
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psnet.ahrq.gov/node/43303/psn-pdf
August 21, 2014 - Barriers and facilitators for taking action after classroom-
based crew resource management training at three ICUs.
August 21, 2014
Kemper PE, van Dyck C, Wagner C, et al. Barriers and facilitators for taking action after classroom-based
crew resource management training at three ICUs. Jt Comm J Qual Patient Saf. 2…
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psnet.ahrq.gov/node/846445/psn-pdf
March 22, 2023 - Formalizing the hidden curriculum of performance
enhancing errors.
March 22, 2023
Kerray FM, Yule SJ, Tambyraja AL. Formalizing the hidden curriculum of performance enhancing errors. J
Surg Educ. 2023;80(5):619-623. doi:10.1016/j.jsurg.2023.01.009.
https://psnet.ahrq.gov/issue/formalizing-hidden-curriculum-perform…
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psnet.ahrq.gov/node/42014/psn-pdf
February 06, 2013 - Diagnostic errors in orthopedic surgery: evaluation of
resident documentation of neurovascular examinations
for orthopedic trauma patients.
February 6, 2013
Tan EW, Ting BL, Jia X, et al. Diagnostic errors in orthopedic surgery: evaluation of resident documentation
of neurovascular examinations for orthopedic trau…
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psnet.ahrq.gov/node/47961/psn-pdf
January 01, 2021 - Patient and physician experience with interhospital
transfer: a qualitative study.
June 2, 2019
Mueller SK, Shannon E, Dalal A, et al. Patient and Physician Experience with Interhospital Transfer: A
Qualitative Study. J Patient Saf. 2021;17(8):e752-e757. doi:10.1097/PTS.0000000000000501.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/854265/psn-pdf
October 04, 2023 - Can AI help doctors come up with better diagnoses?
October 4, 2023
Landro L. Wall Street Journal. September 24, 2023.
https://psnet.ahrq.gov/issue/can-ai-help-doctors-come-better-diagnoses
Artificial intelligence (AI) is being considered as a strong contender in the effort to reduce harmful
diagnostic error, but c…
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psnet.ahrq.gov/node/73415/psn-pdf
June 23, 2021 - Patient safety in dermatology: a ten-year update.
June 23, 2021
Patel J, Otto E, Taylor JS, et al. Dermatol Online J. 2021;27(3).
https://psnet.ahrq.gov/issue/patient-safety-dermatology-ten-year-update
In an update to their 2010 article, this review’s authors summarized the patient safety literature in
dermatology…
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psnet.ahrq.gov/node/764410/psn-pdf
March 02, 2022 - Five strategies for clinicians to advance diagnostic
excellence.
March 2, 2022
Singh H, Connor DM, Dhaliwal G. Five strategies for clinicians to advance diagnostic excellence. BMJ.
2022;376:e068044. doi:10.1136/bmj-2021-068044.
https://psnet.ahrq.gov/issue/five-strategies-clinicians-advance-diagnostic-excellence
…
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psnet.ahrq.gov/node/45970/psn-pdf
March 22, 2017 - A learning health care system using computer-aided
diagnosis.
March 22, 2017
Cahan A, Cimino JJ. A Learning Health Care System Using Computer-Aided Diagnosis. J Med Internet
Res. 2017;19(3):e54. doi:10.2196/jmir.6663.
https://psnet.ahrq.gov/issue/learning-health-care-system-using-computer-aided-diagnosis
Although…
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psnet.ahrq.gov/node/50671/psn-pdf
November 20, 2019 - Critical errors in infrequently performed trauma
procedures after training.
November 20, 2019
Mackenzie CF, Shackelford SA, Tisherman SA, et al. Critical errors in infrequently performed trauma
procedures after training. Surgery. 2019;166(5):835-843. doi:10.1016/j.surg.2019.05.031.
https://psnet.ahrq.gov/issue/cri…
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psnet.ahrq.gov/node/42993/psn-pdf
March 19, 2014 - Baccalaureate nursing students' accounts of medical
mistakes occurring in the clinical setting: implications for
curricula.
March 19, 2014
Noland CM. Baccalaureate nursing students' accounts of medical mistakes occurring in the clinical setting:
implications for curricula. J Nurs Educ. 2014;53(3):S34-7. doi:10.392…
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psnet.ahrq.gov/node/43772/psn-pdf
June 24, 2019 - Betsy Lehman Center for Patient Safety.
June 24, 2019
501 Boylston Street, 5th Floor, Boston, MA, 02116 info@BetsyLehmanCenterMA.gov
https://psnet.ahrq.gov/issue/betsy-lehman-center-patient-safety
The Betsy Lehman Center is a nonregulatory Massachusetts state agency named for Betsy Lehman, the
Boston Globe columni…
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psnet.ahrq.gov/node/46073/psn-pdf
May 30, 2018 - The burnout crisis in American medicine.
May 30, 2018
Xu R. The Atlantic. May 11, 2018.
https://psnet.ahrq.gov/issue/burnout-crisis-american-medicine
Clinician burnout is a growing concern in health care. This magazine article illustrates how ineffective
electronic health record systems contribute to the problem a…
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psnet.ahrq.gov/node/45481/psn-pdf
September 14, 2016 - "Use as directed" can cause confusion for both patients
and practitioners.
September 14, 2016
ISMP Medication Safety Alert! Acute Care Edition. August 25, 2016;21:1-3.
https://psnet.ahrq.gov/issue/use-directed-can-cause-confusion-both-patients-and-practitioners
Reporting the results of a survey on "as directed" in…
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psnet.ahrq.gov/node/46384/psn-pdf
November 14, 2018 - Peggy Lillis Foundation.
November 14, 2018
266 12th Street #6, Brooklyn, NY 11215.
https://psnet.ahrq.gov/issue/peggy-lillis-foundation
Clostridium difficile infections are considered a serious hospital-acquired infection. This grassroots
foundation employs educational, policy, and advocacy strategies aimed at red…
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psnet.ahrq.gov/node/849609/psn-pdf
May 31, 2023 - Impact of diagnostic checklists on the interpretation of
normal and abnormal electrocardiograms.
May 31, 2023
Staal J, Zegers R, Caljouw-Vos J, et al. Impact of diagnostic checklists on the interpretation of normal and
abnormal electrocardiograms. Diagnosis (Berl). 2022;10(2):121-129. doi:10.1515/dx-2022-0092.
htt…
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psnet.ahrq.gov/node/60831/psn-pdf
August 19, 2020 - Telediagnosis for Acute Care: Implications for the Quality
and Safety of Diagnosis.
August 19, 2020
Smith KM, Hunte HE, Graber ML. Rockville MD: Agency for Healthcare Research and Quality; August
2020. AHRQ Publication No. 20-0040-2-EF.
https://psnet.ahrq.gov/issue/telediagnosis-acute-care-implications-quality-and…
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psnet.ahrq.gov/node/60975/psn-pdf
September 30, 2020 - Evidence on Use of Clinical Reasoning Checklists for
Diagnostic Error Reduction.
September 30, 2020
Zwaan L, Staal J. Rockville, MD: Agency for Healthcare Research and Quality; September 2020.
AHRQ Publication No. 20-0040-3-EF.
https://psnet.ahrq.gov/issue/evidence-use-clinical-reasoning-checklists-diagnostic…