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psnet.ahrq.gov/node/35736/psn-pdf
May 27, 2011 - Video capture of clinical care to enhance patient safety.
May 27, 2011
Weinger MB, Gonzales DC, Slagle J, et al. Video capture of clinical care to enhance patient safety. Qual
Saf Health Care. 2004;13(2):136-44.
https://psnet.ahrq.gov/issue/video-capture-clinical-care-enhance-patient-safety
This study describes th…
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psnet.ahrq.gov/node/47945/psn-pdf
August 28, 2019 - Individual and team-based medical error disclosure:
dialectical tensions among health care providers.
August 28, 2019
Jones M, Scarduzio J, Mathews E, et al. Individual and Team-Based Medical Error Disclosure: Dialectical
Tensions Among Health Care Providers. Qual Health Res. 2019;29(8):1096-1108.
doi:10.1177/1049…
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psnet.ahrq.gov/node/48050/psn-pdf
June 05, 2019 - Patients managing medications and reading their visit
notes: a survey of OpenNotes participants.
June 5, 2019
DesRoches CM, Bell SK, Dong Z, et al. Patients Managing Medications and Reading Their Visit Notes: A
Survey of OpenNotes Participants. Ann Intern Med. 2019;171(1):69-71. doi:10.7326/M18-3197.
https://psnet…
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psnet.ahrq.gov/node/38711/psn-pdf
September 02, 2009 - The relationship between computerized physician order
entry and pediatric adverse drug events: a nested
matched case-control study.
September 2, 2009
Yu F, Salas M, Kim Y-I, et al. The relationship between computerized physician order entry and pediatric
adverse drug events: a nested matched case-control study. Ph…
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psnet.ahrq.gov/node/38502/psn-pdf
May 21, 2009 - Early adopters of computerized physician order entry in
hospitals that care for children: a picture of US health
care shortly after the Institute of Medicine reports on
quality.
May 21, 2009
Teufel RJ, Kazley AS, Basco WT. Early adopters of computerized physician order entry in hospitals that
care for children: a…
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psnet.ahrq.gov/node/45790/psn-pdf
January 11, 2017 - Analysis of reported drug interactions: a recipe for harm
to patients.
January 11, 2017
Grissinger M. PA-PSRS Patient Saf Advis. December 2016;13:137-148.
https://psnet.ahrq.gov/issue/analysis-reported-drug-interactions-recipe-harm-patients
Drawing from reports of medication errors submitted over a 7-year period t…
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psnet.ahrq.gov/node/50585/psn-pdf
October 30, 2019 - Introducing the New SOPS Hospital Survey 2.0.
October 30, 2019
Agency for Healthcare Research and Quality. October 30, 2019.
https://psnet.ahrq.gov/issue/updates-hospital-survey-patient-safety-culture
This webinar recording provides information on the updated Hospital Survey on Patient Safety Culture™
(SOPS™) 2.0.…
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psnet.ahrq.gov/node/39400/psn-pdf
June 30, 2011 - Physician order entry or nurse order entry? Comparison
of two implementation strategies for a computerized order
entry system aimed at reducing dosing medication errors.
June 30, 2011
Kazemi A, Fors UGH, Tofighi S, et al. Physician order entry or nurse order entry? Comparison of two
implementation strategies for a…
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psnet.ahrq.gov/node/74140/psn-pdf
December 15, 2015 - The influence of race and gender on pain management: a
systematic literature review.
December 15, 2015
Hampton SB, Cavalier J, Langford R. The influence of race and gender on pain management: a systematic
literature review. Pain Manag Nurs. 2015;16(6):968-977. doi:10.1016/j.pmn.2015.06.009.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/44320/psn-pdf
October 28, 2015 - Interventions for reducing medication errors in children in
hospital.
October 28, 2015
Maaskant JM, Vermeulen H, Apampa B, et al. Interventions for reducing medication errors in children in
hospital. Cochrane Database Syst Rev. 2015;(3):CD006208. doi:10.1002/14651858.CD006208.pub3.
https://psnet.ahrq.gov/issue/int…
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psnet.ahrq.gov/node/50698/psn-pdf
November 27, 2019 - Missed Opportunities for Suicide Risk Assessment
November 27, 2019
Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…
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psnet.ahrq.gov/node/837748/psn-pdf
August 05, 2022 - Challenges of Diabetes Management and Medication
Reconciliation
August 5, 2022
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet].
2022.
https://psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
The Cases
Case #1: A 53-year-old man …
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psnet.ahrq.gov/primer/debriefing-clinical-learning
September 15, 2024 - Debriefing for Clinical Learning
Citation Text:
Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/issue/transitioning-newborns-nicu-home-resource-toolkit
August 01, 2012 - Government Resource
Transitioning Newborns From NICU to Home: A Resource Toolkit.
Citation Text:
Transitioning Newborns From NICU to Home: A Resource Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; December 2013. AHRQ Publication No. 12(14)-0054-EF.
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psnet.ahrq.gov/issue/fda-101-how-use-consumer-complaint-system-and-medwatch
February 15, 2024 - Fact Sheet/FAQs
FDA 101: How to Use the Consumer Complaint System and MedWatch.
Citation Text:
FDA 101: How to Use the Consumer Complaint System and MedWatch. FDA Consumer Health Information. Silver Spring, MD: US Food and Drug Administration; February 27, 2009.
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psnet.ahrq.gov/issue/system-failure-versus-personal-accountability-case-clean-hands
February 16, 2011 - Commentary
System failure versus personal accountability--the case for clean hands.
Citation Text:
Goldmann DA. System failure versus personal accountability--the case for clean hands. N Engl J Med. 2006;355(2):121-3.
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psnet.ahrq.gov/issue/indication-based-prescribing-system-our-future
February 24, 2016 - Newspaper/Magazine Article
Is an indication-based prescribing system in our future?
Citation Text:
Is an indication-based prescribing system in our future? ISMP Medication Safety Alert! Acute Care Edition. November 17, 2016;21:1-5.
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psnet.ahrq.gov/issue/luer-connector-misconnections-under-recognized-potentially-dangerous-events
May 24, 2015 - Multi-use Website
Luer Connector Misconnections: Under-Recognized but Potentially Dangerous Events.
Citation Text:
Luer Connector Misconnections: Under-Recognized but Potentially Dangerous Events. Medical Product Safety Network. Silver Spring, MD; US Food and Drug Administration. Novembe…
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psnet.ahrq.gov/issue/emotional-fallout-culture-blame-and-shame
October 28, 2020 - Commentary
The emotional fallout from the culture of blame and shame.
Citation Text:
Ferguson CC. The emotional fallout from the culture of blame and shame. JAMA Pediatr. 2017;171(12):1141. doi:10.1001/jamapediatrics.2017.2691.
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psnet.ahrq.gov/issue/parents-partners-obtaining-medication-history
March 19, 2019 - Study
Parents as partners in obtaining the medication history.
Citation Text:
Porter SC, Kohane IS, Goldmann DA. Parents as partners in obtaining the medication history. J Am Med Inform Assoc. 2005;12(3):299-305.
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