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psnet.ahrq.gov/web-mm/dont-bite-your-tongue
September 18, 2024 - Don’t Bite Your Tongue.
Citation Text:
Singh NS. Don’t Bite Your Tongue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/39538/psn-pdf
May 19, 2010 - CPOE: strategies for success.
May 19, 2010
Manor PJ. CPOE: Strategies for success. Nurs Manage. 2010;41(5):18-20.
doi:10.1097/01.NUMA.0000372028.99240.7f.
https://psnet.ahrq.gov/issue/cpoe-strategies-success
This commentary reviews tactics to engage nurses in computerized provider order entry (CPOE)
implementatio…
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psnet.ahrq.gov/node/34631/psn-pdf
December 23, 2016 - Sentinel Event Alert.
December 23, 2016
Oakbrook Terrace, IL: The Joint Commission.
https://psnet.ahrq.gov/issue/sentinel-event-alert
This newsletter provides guidance to health care organizations for responding to commonly reported
incidents. The Joint Commission issues these sentinel event alerts to review selec…
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psnet.ahrq.gov/node/34600/psn-pdf
March 28, 2005 - Handoffs and fumbles.
March 28, 2005
Wachter RM, Shojania KG. Chapter in: Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind
America's Terrifying Epidemic of Medical Mistakes. New York, NY: Rugged Land, LLC; 2004.
https://psnet.ahrq.gov/issue/handoffs-and-fumbles
Personal stories illustrate the systems i…
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psnet.ahrq.gov/node/34130/psn-pdf
December 14, 2016 - CRICO.
December 14, 2016
1325 Boylston Street, Boston, MA 02215
https://psnet.ahrq.gov/issue/crico
CRICO/Risk Management Foundation of the Harvard Medical Institutions, provides evidence-based risk
management, loss prevention, and patient safety services to CRICO-insured physicians, office practices, all…
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psnet.ahrq.gov/node/35137/psn-pdf
May 27, 2011 - Drug errors show need for tech aid.
May 27, 2011
Landro L.
https://psnet.ahrq.gov/issue/drug-errors-show-need-tech-aid
The article discusses the importance of using computerized physician order entry systems that provide
more sophisticated alerts, such as drug dosages and strategies for monitoring patients, to red…
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psnet.ahrq.gov/node/836850/psn-pdf
March 31, 2022 - Annual Perspective: Topics in Medication Safety
March 31, 2022
Harris IB, Dowell P, Mossburg SE. Annual Perspective: Topics in Medication Safety. PSNet [internet].
2022.
https://psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
Introduction
Issues with medication management and errors in medi…
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psnet.ahrq.gov/node/60858/psn-pdf
August 26, 2020 - When the Meds Don’t Reach the Bed
August 26, 2020
Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
The Case
A 69-year-old man with cognitive impairment and marginal housing was admitted for acute exacerbation of
chronic obs…
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psnet.ahrq.gov/node/836840/psn-pdf
April 22, 2021 - The Johns Hopkins Venous Thromboembolism (VTE)
Collaborative Studies and Implements Methods to Prevent
Avoidable Cases of Hospital Associated VTE
April 7, 2022
https://psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-
implements-methods
Summary
Venous thromboembolism (…
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psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - Danger in Disruption
Citation Text:
Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - Are You Mrs. A? An Issue of Identification Over Telephone
Citation Text:
Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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…
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psnet.ahrq.gov/node/49513/psn-pdf
July 01, 2006 - Moving Pains
July 1, 2006
Schell H, Wachter R. Moving Pains. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/moving-pains
Case Objectives
Appreciate the risk posed by intrahospital transport
Identify key features of current transport practice and policies
Propose interventions that might improve safety of …
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psnet.ahrq.gov/Information/Disclaimer
May 18, 2025 - External Link Disclaimer Notice
This graphic notice means that you are leaving AHRQ Patient Safety Network.
External links provide additional information that is consistent with the intended purpose of a Federal site.
The Department of Health and Human Services (HHS) cannot attest to the accuracy of informat…
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psnet.ahrq.gov/issue/how-will-we-know-patients-are-safer-organization-wide-approach-measuring-and-improving-safety
May 20, 2009 - Study
How will we know patients are safer? An organization-wide approach to measuring and improving safety.
Citation Text:
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…
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psnet.ahrq.gov/issue/implementing-medication-reconciliation-outpatient-pediatrics
September 23, 2020 - Study
Implementing medication reconciliation in outpatient pediatrics.
Citation Text:
Rappaport DI, Collins B, Koster A, et al. Implementing medication reconciliation in outpatient pediatrics. Pediatrics. 2011;128(6):e1600-7. doi:10.1542/peds.2011-0993.
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psnet.ahrq.gov/issue/regret-among-primary-care-physicians-survey-diagnostic-decisions
November 13, 2019 - Study
Regret among primary care physicians: a survey of diagnostic decisions.
Citation Text:
Müller BS, Donner-Banzhoff N, Beyer M, et al. Regret among primary care physicians: a survey of diagnostic decisions. BMC Fam Pract. 2020;21(1). doi:10.1186/s12875-020-01125-w.
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…
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psnet.ahrq.gov/issue/framework-evaluating-appropriateness-clinical-decision-support-alerts-and-responses
March 21, 2017 - Study
A framework for evaluating the appropriateness of clinical decision support alerts and responses.
Citation Text:
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…
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psnet.ahrq.gov/issue/psychological-impact-and-recovery-after-involvement-patient-safety-incident-repeated-measures
September 19, 2016 - Study
Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis.
Citation Text:
Van Gerven E, Bruyneel L, Panella M, et al. Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis.…
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psnet.ahrq.gov/issue/technology-induced-errors-associated-computerized-provider-order-entry-software-older
September 13, 2023 - Study
Technology-induced errors associated with computerized provider order entry software for older patients.
Citation Text:
Vélez-Díaz-Pallarés M, Díaz AMÁ, Caro TG, et al. Technology-induced errors associated with computerized provider order entry software for older patients. Int J Cl…
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psnet.ahrq.gov/issue/secondary-traumatic-stress-ob-gyn-mixed-methods-analysis-assessing-physician-impact-and-needs
July 07, 2021 - Study
Secondary traumatic stress in ob-gyn: a mixed methods analysis assessing physician impact and needs.
Citation Text:
Kruper A, Domeyer-Klenske A, Treat R, et al. Secondary traumatic stress in ob-gyn: a mixed methods analysis assessing physician impact and needs. J Surg Educ. 2021;78…