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psnet.ahrq.gov/node/44008/psn-pdf
April 27, 2015 - We need to talk: primary care provider communication at
discharge in the era of a shared electronic medical
record.
April 27, 2015
Sheu L, Fung K, Mourad M, et al. We need to talk: Primary care provider communication at discharge in
the era of a shared electronic medical record. J Hosp Med. 2015;10(5):307-10. doi:…
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psnet.ahrq.gov/node/42722/psn-pdf
November 13, 2013 - Patient safety perspectives of providers and nurses: the
experience of a rural ambulatory care practice using an
EHR with e-prescribing.
November 13, 2013
Bramble JD, Abbott AA, Fuji KT, et al. Patient safety perspectives of providers and nurses: the experience
of a rural ambulatory care practice using an EHR with…
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psnet.ahrq.gov/node/60349/psn-pdf
May 20, 2020 - Health care provider factors associated with patient-
reported adverse events and harm.
May 20, 2020
Giardina TD, Royse KE, Khanna A, et al. Health care provider factors associated with patient-reported
adverse events and harm. Jt Comm J Qual Patient Saf. 2020;46(5):282-290.
doi:10.1016/j.jcjq.2020.02.004.
https:…
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psnet.ahrq.gov/node/37571/psn-pdf
February 27, 2008 - Comparing measures of patient safety for inpatient care
provided to veterans within and outside the VA system in
New York.
February 27, 2008
Weeks WB, West AN, Rosen AK, et al. Comparing measures of patient safety for inpatient care provided to
veterans within and outside the VA system in New York. Qual Saf Health…
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psnet.ahrq.gov/node/47495/psn-pdf
October 31, 2018 - Developing and evaluating clinical leadership
interventions for frontline healthcare providers: a review
of the literature.
October 31, 2018
Mianda S, Voce A. Developing and evaluating clinical leadership interventions for frontline healthcare
providers: a review of the literature. BMC Health Serv Res. 2018;18(1):…
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psnet.ahrq.gov/node/44323/psn-pdf
December 04, 2016 - Client, caregiver, and provider perspectives of safety in
palliative home care: a mixed method design.
December 4, 2016
Lang A, Toon L, Cohen SR, et al. Client, caregiver, and provider perspectives of safety in palliative home
care: a mixed method design. Safety Health. 2015;1(1):3. doi:10.1186/2056-5917-1-3.
http…
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psnet.ahrq.gov/node/844545/psn-pdf
February 15, 2023 - Providers' and patients' perspectives on diagnostic errors
in the acute care setting.
February 15, 2023
Schnock KO, Garber A, Fraser H, et al. Providers' and patients' perspectives on diagnostic errors in the
acute care setting. Jt Comm J Qual Patient Saf. 2023;49(2):89-97. doi:10.1016/j.jcjq.2022.11.009.
https://…
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psnet.ahrq.gov/node/43966/psn-pdf
April 03, 2017 - TRIAD VII: do prehospital providers understand Physician
Orders for Life-Sustaining Treatment documents?
April 3, 2017
Mirarchi FL, Cammarata C, Zerkle SW, et al. TRIAD VII: do prehospital providers understand Physician
Orders for Life-Sustaining Treatment documents? J Patient Saf. 2015;11(1):9-17.
doi:10.1097/PTS…
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psnet.ahrq.gov/node/47823/psn-pdf
March 13, 2019 - Greater Focus on Credentialing Needed to Prevent
Disqualified Providers From Delivering Patient Care.
March 13, 2019
Washington, DC: United States Government Accountability Office; February 2019. Publication GAO-19-6.
https://psnet.ahrq.gov/issue/greater-focus-credentialing-needed-prevent-disqualified-providers-del…
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psnet.ahrq.gov/node/47688/psn-pdf
March 19, 2019 - Evaluation of an electronic health record structured
discharge summary to provide real time adverse event
reporting in thoracic surgery.
March 19, 2019
Graham AJ, Ocampo W, Southern DA, et al. Evaluation of an electronic health record structured discharge
summary to provide real time adverse event reporting in tho…
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psnet.ahrq.gov/node/43634/psn-pdf
November 05, 2014 - Safety in numbers: lack of evidence to indicate the
number of physicians needed to provide safe acute
medical care.
November 5, 2014
Sabin J, Subbe CP, Vaughan L, et al. Safety in numbers: lack of evidence to indicate the number of
physicians needed to provide safe acute medical care. Clin Med (Lond). 2014;14(5):4…
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psnet.ahrq.gov/node/45284/psn-pdf
January 27, 2019 - Emergency medical services provider pediatric adverse
event rate varies by call origin pediatric emergency care.
January 27, 2019
Jones D, Hansen M, Van Otterloo J, et al. Emergency Medical Services Provider Pediatric Adverse Event
Rate Varies by Call Origin. Pediatr Emerg Care. 2018;34(12):862-865.
doi:10.1097/PE…
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psnet.ahrq.gov/node/74135/psn-pdf
December 01, 2021 - Communication regarding adverse neonatal birth events:
experiences of parents and clinicians.
December 1, 2021
Loren DL, Lyerly AD, Lipira L, et al. Communication regarding adverse neonatal birth events: experiences
of parents and clinicians. J Patient Saf Risk Manag. 2021;26(5):200-206.
doi:10.1177/25160435211017…
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psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
July 02, 2019 - Critical Order Set Change and Critical Limb Ischemia
Citation Text:
Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/850361/psn-pdf
June 14, 2023 - Critical Echocardiogram Result Lost to Follow-up
June 14, 2023
Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
The Case
A 63-year-old man with history of stroke, systolic heart failure, and ventric…
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psnet.ahrq.gov/web-mm/poorly-advanced-directives
August 01, 2018 - Poorly Advanced Directives
Citation Text:
Anderson WG. Poorly Advanced Directives. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
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psnet.ahrq.gov/node/33717/psn-pdf
September 01, 2011 - Incident Reporting: More Attention to the Safety Action
Feedback Loop, Please
September 1, 2011
Nuckols TK. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. PSNet
[internet]. 2011.
https://psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
…
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psnet.ahrq.gov/web-mm/after-visit-confusion
August 21, 2007 - After-Visit Confusion
Citation Text:
Ventres W. After-Visit Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/47267/psn-pdf
September 05, 2018 - The national cost of adverse drug events resulting from
inappropriate medication-related alert overrides in the
United States.
September 5, 2018
Slight SP, Seger DL, Franz C, et al. The national cost of adverse drug events resulting from inappropriate
medication-related alert overrides in the United States. J Am M…
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psnet.ahrq.gov/node/46606/psn-pdf
July 10, 2019 - Implementation of a mock root cause analysis to provide
simulated patient safety training.
July 10, 2019
Murphy M, Duff J, Whitney J, et al. Implementation of a mock root cause analysis to provide simulated
patient safety training. BMJ Open Qual. 2017;6(2). doi:10.1136/bmjoq-2017-000096.
https://psnet.ahrq.gov/iss…