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  1. Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2019-2021. | PSNet

    psnet.ahrq.gov/issue/ranking-rate-state-medical-boards-serious-disciplinary-actions-2019-2021
    October 05, 2016 - Book/Report Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2019-2021. Citation Text: Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2019-2021. Wolfe SW, Oshel RE. Washington, DC: Public Citizen; August 16, 2023. Copy C…

  2. Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. | PSNet

    psnet.ahrq.gov/issue/closing-loop-guide-safer-ambulatory-referrals-ehr-era
    July 12, 2017 - Book/Report Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. Citation Text: Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for Healthcare Imp…

  3. Tacit Handover, Overt Mishap | PSNet

    psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
    August 01, 2006 - Tacit Handover, Overt Mishap Citation Text: Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

  4. To Transfer or Not to Transfer | PSNet

    psnet.ahrq.gov/web-mm/transfer-or-not-transfer
    November 23, 2016 - SPOTLIGHT CASE To Transfer or Not to Transfer Citation Text: Pines JM. To Transfer or Not to Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853773/psn-pdf
    September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 2023 Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side The Case A first-year orthopedic surgery resident was consulted…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49712/psn-pdf
    June 01, 2014 - May I Have Another?—Medication Error June 1, 2014 Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error The Case A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a pharmacology-tra…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72616/psn-pdf
    December 22, 2020 - Adverse Events in Dentistry December 22, 2020 Kalenderian E, Walji MF, Fitall E, et al. Adverse Events in Dentistry. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/adverse-events-dentistry Introduction Similar to many other healthcare settings, dentistry carries with it inherent patient safety risks. D…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42342/psn-pdf
    December 31, 2014 - The safety of electronic prescribing: manifestations, mechanisms, and rates of system-related errors associated with two commercial systems in hospitals. December 31, 2014 Westbrook JI, Baysari M, Li L, et al. The safety of electronic prescribing: manifestations, mechanisms, and rates of system-related errors asso…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45156/psn-pdf
    June 22, 2017 - Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals. June 22, 2017 Cresswell K, Mozaffar H, Lee L, et al. Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals. BMJ Qual Saf. 2017;26(7):542-551. doi:10.1136/bmjqs-2015-005149. h…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41539/psn-pdf
    January 07, 2015 - Dying for the weekend: a retrospective cohort study on the association between day of hospital presentation and the quality and safety of stroke care. January 7, 2015 Palmer WL, Bottle A, Davie C, et al. Dying for the weekend: a retrospective cohort study on the association between day of hospital presentation and…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45356/psn-pdf
    May 09, 2017 - Screening for medication errors using an outlier detection system. May 9, 2017 Schiff G, Volk LA, Volodarskaya M, et al. Screening for medication errors using an outlier detection system. J Am Med Inform Assoc. 2017;24(2):281-287. doi:10.1093/jamia/ocw171. https://psnet.ahrq.gov/issue/screening-medication-errors-u…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46616/psn-pdf
    July 02, 2019 - Medication-related clinical decision support alert overrides in inpatients. July 2, 2019 Nanji KC, Seger DL, Slight SP, et al. Medication-related clinical decision support alert overrides in inpatients. J Am Med Inform Assoc. 2018;25(5):476-481. doi:10.1093/jamia/ocx115. https://psnet.ahrq.gov/issue/medication-rel…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40785/psn-pdf
    May 04, 2012 - A framework for evaluating the appropriateness of clinical decision support alerts and responses. May 4, 2012 McCoy AB, Waitman LR, Lewis JB, et al. A framework for evaluating the appropriateness of clinical decision support alerts and responses. J Am Med Inform Assoc. 2012;19(3):346-52. doi:10.1136/amiajnl- 2011-…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45402/psn-pdf
    November 01, 2017 - Potentially preventable 30-day hospital readmissions at a children's hospital. November 1, 2017 Toomey SL, Peltz A, Loren S, et al. Potentially Preventable 30-Day Hospital Readmissions at a Children's Hospital. Pediatrics. 2016;138(2). doi:10.1542/peds.2015-4182. https://psnet.ahrq.gov/issue/potentially-preventabl…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38076/psn-pdf
    February 15, 2011 - Consequences of inadequate sign-out for patient care. February 15, 2011 Horwitz LI, Moin T, Krumholz HM, et al. Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;168(16):1755-60. doi:10.1001/archinte.168.16.1755. https://psnet.ahrq.gov/issue/consequences-inadequate-sign-out-patient-care W…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38553/psn-pdf
    April 14, 2010 - The effect of computerized physician order entry on medication prescription errors and clinical outcome in pediatric and intensive care: a systematic review. April 14, 2010 van Rosse F, Maat B, Rademaker CMA, et al. The effect of computerized physician order entry on medication prescription errors and clinical out…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38449/psn-pdf
    March 04, 2009 - A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures. March 4, 2009 Krimsky WS, Mroz IB, McIlwaine JK, et al. A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures. Q…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38536/psn-pdf
    February 03, 2011 - Association between hospital-reported Leapfrog Safe Practices scores and inpatient mortality. February 3, 2011 Werner RM, McNutt RA. A New Strategy to Improve Quality. JAMA. 2009;301(13). doi:10.1001/jama.2009.423. https://psnet.ahrq.gov/issue/association-between-hospital-reported-leapfrog-safe-practices-scores-an…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35979/psn-pdf
    September 17, 2010 - How will we know patients are safer? An organization- wide approach to measuring and improving safety. September 17, 2010 Pronovost P, Holzmueller CG, Needham DM, et al. How will we know patients are safer? An organization- wide approach to measuring and improving safety. Crit Care Med. 2006;34(7):1988-95. https:/…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48176/psn-pdf
    July 31, 2019 - Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands. July 31, 2019 Vanhaecht K, Seys D, Schouten L, et al. Duration of second victim symptoms in the aftermath of a patient safety incident and ass…
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