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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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 …
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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.…
  12. Psn-Pdf (pdf file)

    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…
  13. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
  14. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
  15. Psn-Pdf (pdf file)

    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 …
  16. Psn-Pdf (pdf file)

    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…
  17. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
  18. 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…
  19. Psn-Pdf (pdf file)

    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…
  20. 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…

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