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psnet.ahrq.gov/node/863217/psn-pdf
February 28, 2024 - Interpreting and coding causal relationships for quality
and safety using ICD-11.
February 28, 2024
Januel J-M, Southern DA, Ghali WA. Interpreting and coding causal relationships for quality and safety
using ICD-11. BMC Med Inform Decis Mak. 2023;21(Suppl 6):385. doi:10.1186/s12911-023-02363-5.
https://psnet.ahrq…
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psnet.ahrq.gov/node/44996/psn-pdf
June 29, 2016 - Residents' numeric inputting error in computerized
physician order entry prescription.
June 29, 2016
Wu X, Wu C, Zhang K, et al. Residents' numeric inputting error in computerized physician order entry
prescription. Int J Med Inform. 2016;88:25-33. doi:10.1016/j.ijmedinf.2016.01.002.
https://psnet.ahrq.gov/issue/r…
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psnet.ahrq.gov/node/72569/psn-pdf
January 01, 2021 - Risk factors associated with medication ordering errors.
December 16, 2020
Abraham J, Galanter WL, Touchette DR, et al. Risk factors associated with medication ordering errors. J
Am Med Inform Assoc. 2021;18(1):86-94. doi:10.1093/jamia/ocaa264.
https://psnet.ahrq.gov/issue/risk-factors-associated-medication-orderin…
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psnet.ahrq.gov/node/45149/psn-pdf
September 19, 2016 - Care at the point of impact: insights into the second-
victim experience.
September 19, 2016
Scott SD, McCoig MM. Care at the point of impact: Insights into the second-victim experience. J Healthc
Risk Manag. 2016;35(4):6-13. doi:10.1002/jhrm.21218.
https://psnet.ahrq.gov/issue/care-point-impact-insights-second-vi…
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psnet.ahrq.gov/node/43580/psn-pdf
October 01, 2014 - Reducing medication errors in critical care: a multimodal
approach.
October 1, 2014
Kruer RM, Jarrell AS, Latif A. Reducing medication errors in critical care: a multimodal approach. Clin
Pharmacol. 2014;6:117-26. doi:10.2147/CPAA.S48530.
https://psnet.ahrq.gov/issue/reducing-medication-errors-critical-care-multim…
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psnet.ahrq.gov/node/43958/psn-pdf
April 22, 2015 - Non-intercepted dose errors in prescribing antineoplastic
treatment: a prospective, comparative cohort study.
April 22, 2015
Mattsson TO, Holm B, Michelsen H, et al. Non-intercepted dose errors in prescribing anti-neoplastic
treatment: a prospective, comparative cohort study. Ann Oncol. 2015;26(5):981-6.
doi:10.10…
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psnet.ahrq.gov/node/854246/psn-pdf
October 04, 2023 - Inpatient EHR user experience and hospital EHR safety
performance.
October 4, 2023
Classen DC, Longhurst CA, Davis T, et al. Inpatient EHR user experience and hospital EHR safety
performance. JAMA Netw Open. 2023;6(9):e2333152. doi:10.1001/jamanetworkopen.2023.33152.
https://psnet.ahrq.gov/issue/inpatient-ehr-user…
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psnet.ahrq.gov/node/44253/psn-pdf
August 24, 2015 - Acceptability and feasibility of the Leapfrog computerized
physician order entry evaluation tool for hospitals outside
the United States.
August 24, 2015
Cho IS, Lee J-H, Choi S-K, et al. Acceptability and feasibility of the Leapfrog computerized physician order
entry evaluation tool for hospitals outside the Unit…
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psnet.ahrq.gov/node/35850/psn-pdf
May 27, 2011 - Computerization can create safety hazards: a bar-coding
near miss.
May 27, 2011
McDonald CJ. Computerization can create safety hazards: a bar-coding near miss. Ann Intern Med.
2006;144(7):510-6.
https://psnet.ahrq.gov/issue/computerization-can-create-safety-hazards-bar-coding-near-miss
This case study shares the …
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psnet.ahrq.gov/node/837860/psn-pdf
August 17, 2022 - Alcoholism and American healthcare: the case for a
patient safety approach.
August 17, 2022
Zipperer L, Ryan R, Jones B. Alcoholism and American healthcare: the case for a patient safety approach.
J Patient Saf Risk Manag. 2022;27(5):201-208. doi:10.1177/25160435221117952.
https://psnet.ahrq.gov/issue/alcoholism-a…
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psnet.ahrq.gov/node/44790/psn-pdf
March 15, 2016 - The role of emotion in patient safety: are we brave
enough to scratch beneath the surface?
March 15, 2016
Heyhoe J, Birks Y, Harrison R, et al. The role of emotion in patient safety: Are we brave enough to scratch
beneath the surface? J R Soc Med. 2016;109(2):52-8. doi:10.1177/0141076815620614.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/47329/psn-pdf
August 29, 2018 - With scarce access to interpreters, immigrants struggle to
understand doctors' orders.
August 29, 2018
Eldred SM. Health Shots. National Public Radio. August 15, 2018.
https://psnet.ahrq.gov/issue/scarce-access-interpreters-immigrants-struggle-understand-doctors-orders
Using professional interpreters can avert ris…
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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - Mismanagement of Delirium
Citation Text:
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
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psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - SPOTLIGHT CASE
Moving Pains
Citation Text:
Schell H, Wachter R. Moving Pains. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …
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psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - Debriefing for Clinical Learning
November 18, 2021
Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/debriefing-clinical-learning
Updated in September 2021. Originally published in December 2011 by researchers at the University of
California, S…
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - Continuity Errors in Resident Clinic
Citation Text:
Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL Dec Spotlight_Code Status vs Care Status.pptx
Spotlight
Code Status vs. Care Status
Source and Credits
• This presentation is based on the December 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Rebe…
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psnet.ahrq.gov/node/33806/psn-pdf
April 01, 2016 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
Editor's note: Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of
Pediatrics a…
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psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
February 21, 2024 - The Safety Challenges of Supervision and Night Coverage in Academic Residency
Citation Text:
Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019…