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psnet.ahrq.gov/node/38379/psn-pdf
April 30, 2014 - Clinical information technologies and inpatient outcomes:
a multiple hospital study.
April 30, 2014
Amarasingham R, Plantinga L, Diener-West M, et al. Clinical information technologies and inpatient
outcomes: a multiple hospital study. Arch Intern Med. 2009;169(2):108-14.
doi:10.1001/archinternmed.2008.520.
https…
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psnet.ahrq.gov/node/46839/psn-pdf
December 03, 2018 - Trends in survival after in-hospital cardiac arrest during
nights and weekends.
December 3, 2018
Ofoma UR, Basnet S, Berger A, et al. Trends in Survival After In-Hospital Cardiac Arrest During Nights and
Weekends. J Am Coll Cardiol. 2018;71(4):402-411. doi:10.1016/j.jacc.2017.11.043.
https://psnet.ahrq.gov/issue/t…
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psnet.ahrq.gov/node/49820/psn-pdf
February 01, 2018 - Returning Home Safely
February 1, 2018
Toles M. Returning Home Safely. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/returning-home-safely
The Case
A 72-year-old man was admitted to the hospital after a fall at home resulting in a right humerus fracture and
shoulder dislocation, as well as other injuries …
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psnet.ahrq.gov/web-mm/refused-medication-error
November 01, 2005 - Refused Medication Error
Citation Text:
Foley M. Refused Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/33685/psn-pdf
May 01, 2009 - In Conversation with…William B. Weeks, MD, MBA
May 1, 2009
In Conversation with…William B. Weeks, MD, MBA. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
Editor's note: William B. Weeks, MD, MBA, is Associate Professor of Psychiatry and of Community and
Family M…
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psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation
February 01, 2003 - The Unintended Consequences of Florida Medical Liability Legislation
Paul Barach, MD, MPH | December 1, 2005
View more articles from the same authors.
Citation Text:
Barach P. The Unintended Consequences of Florida Medical Liability Legislation. PSNet [internet].…
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psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
February 01, 2019 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room
Citation Text:
Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. Rockville (MD): Agency for H…
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - SPOTLIGHT CASE
A Weighty Mistake
Citation Text:
Bokser SJ. A Weighty Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - SPOTLIGHT CASE
Bad Writing, Wrong Medication
Citation Text:
Devine B. Bad Writing, Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/33567/psn-pdf
June 15, 2024 - Handoffs
June 15, 2024
Handoffs and Signouts. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/handoffs
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 2024.
Backgroun…
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psnet.ahrq.gov/issue/mirror-mirror-wall-update-quality-american-health-care-through-patients-lens
August 15, 2007 - Book/Report
Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens.
Citation Text:
Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens. Davis K, Schoen S, Schoenbaum SC, et al. New Yo…
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psnet.ahrq.gov/issue/what-prevents-incident-disclosure-and-what-can-be-done-promote-it
February 20, 2012 - Study
What prevents incident disclosure, and what can be done to promote it?
Citation Text:
Iedema R, Allen S, Sorensen R, et al. What prevents incident disclosure, and what can be done to promote it? Jt Comm J Qual Patient Saf. 2011;37(9):409-417.
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G…
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psnet.ahrq.gov/issue/path-diagnostic-excellence-includes-feedback-calibrate-how-clinicians-think
May 04, 2022 - Commentary
Emerging Classic
The path to diagnostic excellence includes feedback to calibrate how clinicians think.
Citation Text:
Meyer AND, Singh H. The Path to Diagnostic Excellence Includes Feedback to Calibrate How Clinicians Think. JAMA. 2019;321(8):737-738…
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psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005-hhs-guidance-regarding-patient-safety-work
December 24, 2008 - Government Resource
Patient Safety and Quality Improvement Act of 2005--HHS guidance regarding patient safety work product and providers' external obligations.
Citation Text:
Patient Safety and Quality Improvement Act of 2005--HHS guidance regarding patient safety work product and provid…
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psnet.ahrq.gov/issue/healthcare-provider-complaints-emergency-department-preliminary-report-new-quality
October 07, 2013 - Study
Healthcare provider complaints to the emergency department: a preliminary report on a new quality improvement instrument.
Citation Text:
Griffey RT, Bohan JS. Healthcare provider complaints to the emergency department: a preliminary report on a new quality improvement instrument.…
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psnet.ahrq.gov/issue/research-nursing-handoffs-medical-and-surgical-settings-integrative-review
October 19, 2011 - Review
Research on nursing handoffs for medical and surgical settings: an integrative review.
Citation Text:
Staggers N, Blaz JW. Research on nursing handoffs for medical and surgical settings: an integrative review. J Adv Nurs. 2013;69(2):247-62. doi:10.1111/j.1365-2648.2012.06087.x. …
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psnet.ahrq.gov/issue/medication-safety-emergency-medical-services-approaching-evidence-based-method-verification
September 28, 2022 - Study
Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors.
Citation Text:
Misasi P, Keebler JR. Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors. Ther …
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psnet.ahrq.gov/issue/medication-discrepancies-integrated-electronic-health-records
July 21, 2021 - Study
Medication discrepancies in integrated electronic health records.
Citation Text:
Linsky A, Simon SR. Medication discrepancies in integrated electronic health records. BMJ Qual Saf. 2013;22(2):103-9. doi:10.1136/bmjqs-2012-001301.
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psnet.ahrq.gov/issue/analyzing-communication-errors-air-medical-transport-service
August 04, 2021 - Study
Analyzing communication errors in an air medical transport service.
Citation Text:
Dalto JD, Weir C, Thomas F. Analyzing communication errors in an air medical transport service. Air Med J. 2013;32(3):129-37. doi:10.1016/j.amj.2012.10.019.
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psnet.ahrq.gov/issue/potential-false-positive-results-antigen-tests-rapid-detection-sars-cov-2-letter-clinical
April 08, 2020 - Press Release/Announcement
Potential for false positive results with antigen tests for rapid detection of SARS-CoV-2--letter to clinical laboratory staff and health care providers.
Citation Text:
Potential for false positive results with antigen tests for rapid detection of SARS-CoV-2--l…