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psnet.ahrq.gov/node/38817/psn-pdf
April 04, 2011 - Adequacy of hospital discharge summaries in
documenting tests with pending results and outpatient
follow-up providers.
April 4, 2011
Were MC, Li X, Kesterson J, et al. Adequacy of hospital discharge summaries in documenting tests with
pending results and outpatient follow-up providers. J Gen Intern Med. 2009;24(9)…
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psnet.ahrq.gov/node/46829/psn-pdf
July 23, 2018 - Quality and variability of patient directions in electronic
prescriptions in the ambulatory care setting.
July 23, 2018
Yang Y, Ward-Charlerie S, Dhavle AA, et al. Quality and Variability of Patient Directions in Electronic
Prescriptions in the Ambulatory Care Setting. J Manag Care Spec Pharm. 2018;24(7):691-699.
…
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psnet.ahrq.gov/node/43695/psn-pdf
August 02, 2015 - The medical liability climate and prospects for reform.
August 2, 2015
Mello MM, Studdert DM, Kachalia A. The medical liability climate and prospects for reform. JAMA.
2014;312(20):2146-55. doi:10.1001/jama.2014.10705.
https://psnet.ahrq.gov/issue/medical-liability-climate-and-prospects-reform
This review of natio…
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psnet.ahrq.gov/node/46864/psn-pdf
August 17, 2018 - Prospective evaluation of medication-related clinical
decision support over-rides in the intensive care unit.
August 17, 2018
Wong A, Amato MG, Seger DL, et al. Prospective evaluation of medication-related clinical decision support
over-rides in the intensive care unit. BMJ Qual Saf. 2018;27(9):718-724. doi:10.1136…
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psnet.ahrq.gov/node/44369/psn-pdf
July 16, 2018 - The impact of a computerized physician order entry
system on medical errors with antineoplastic drugs 5
years after its implementation.
July 16, 2018
Cuervo S, Sanchis R, Lopez P, et al. The impact of a computerized physician order entry system on
medical errors with antineoplastic drugs 5 years after its implemen…
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psnet.ahrq.gov/node/43653/psn-pdf
January 01, 2015 - Evaluating inpatient mortality: a new electronic review
process that gathers information from front-line
providers.
December 19, 2014
Provenzano A, Rohan S, Trevejo E, et al. Evaluating inpatient mortality: a new electronic review process
that gathers information from front-line providers. BMJ Qual Saf. 2015;24(1)…
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psnet.ahrq.gov/node/41535/psn-pdf
December 31, 2014 - Understanding and preventing wrong-patient electronic
orders: a randomized controlled trial.
December 31, 2014
Adelman JS, Kalkut GE, Schechter CB, et al. Understanding and preventing wrong-patient electronic
orders: a randomized controlled trial. J Am Med Inform Assoc. 2013;20(2):305-310. doi:10.1136/amiajnl-
201…
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psnet.ahrq.gov/node/38829/psn-pdf
January 03, 2017 - Implementing standardized operating room briefings and
debriefings at a large regional medical center.
January 3, 2017
Berenholtz SM, Schumacher K, Hayanga AJ, et al. Implementing standardized operating room briefings
and debriefings at a large regional medical center. Jt Comm J Qual Patient Saf. 2009;35(8):391-7.
…
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psnet.ahrq.gov/web-mm/code-status-vs-care-status
September 30, 2020 - SPOTLIGHT CASE
Code Status vs. Care Status
Citation Text:
Krisman RK, Spero H. Code Status vs. Care Status. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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Format:
Google Scholar BibTeX End…
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psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - SPOTLIGHT CASE
Despite Clues, Failed to Rescue
Citation Text:
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar BibTeX EndN…
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psnet.ahrq.gov/node/863641/psn-pdf
February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety
Teamwork Training
February 28, 2024
Haugstetter M, Hines S, Sousane Z, et al. Revising TeamSTEPPS: The Evolution of Patient Safety
Teamwork Training. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork…
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psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - Reconciling Records
November 1, 2010
Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/reconciling-records
The Cases
Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local
teaching hospital. When discharged, h…
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/node/853772/psn-pdf
September 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not
Interchangeable
September 27, 2023
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
The Case
A fourteen-ye…
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psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
September 01, 2011 - In Conversation With…Kaveh G. Shojania, MD
September 1, 2011
Also Read an Essay
Citation Text:
In Conversation With…Kaveh G. Shojania, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx
Spotlight
The Dose Makes the Poison: Medication Error During
Procedural Sedation in the Pediatric Emergency
Department
Source and Credits
• This presentation is based on the April 2023 AH…
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psnet.ahrq.gov/node/43865/psn-pdf
May 01, 2015 - Computerised physician order entry-related medication
errors: analysis of reported errors and vulnerability
testing of current systems.
May 1, 2015
Schiff GD, Amato MG, Eguale T, et al. Computerised physician order entry-related medication errors:
analysis of reported errors and vulnerability testing of current sy…
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psnet.ahrq.gov/node/42395/psn-pdf
July 31, 2013 - Return on investment for vendor computerized physician
order entry in four community hospitals: the importance
of decision support.
July 31, 2013
Zimlichman E, Keohane C, Franz C, et al. Return on investment for vendor computerized physician order
entry in four community hospitals: the importance of decision suppo…
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psnet.ahrq.gov/node/47694/psn-pdf
February 06, 2019 - Association of pharmaceutical industry marketing of
opioid products with mortality from opioid-related
overdoses.
February 6, 2019
Hadland SE, Rivera-Aguirre A, Marshall BDL, et al. Association of Pharmaceutical Industry Marketing of
Opioid Products With Mortality From Opioid-Related Overdoses. JAMA Netw Open. 201…
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psnet.ahrq.gov/issue/isqua-networks
January 29, 2021 - Multi-use Website
ISQua Networks.
Citation Text:
ISQua Networks. International Society for Quality in Health Care.
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