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psnet.ahrq.gov/node/40526/psn-pdf
June 15, 2011 - Critical drug–drug interactions for use in electronic health
records systems with computerized physician order
entry: review of leading approaches.
June 15, 2011
Classen DC, Phansalkar S, Bates DW. Critical Drug-Drug Interactions for Use in Electronic Health Records
Systems With Computerized Physician Order Entry.…
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psnet.ahrq.gov/node/41986/psn-pdf
January 23, 2013 - Slow progress on meeting hospital safety standards:
learning from the Leapfrog Group's efforts.
January 23, 2013
Moran J, Scanlon D. Slow progress on meeting hospital safety standards: learning from the Leapfrog
Group's efforts. Health Aff (Millwood). 2013;32(1):27-35. doi:10.1377/hlthaff.2011.0056.
https://psnet.…
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psnet.ahrq.gov/node/48187/psn-pdf
August 21, 2019 - How medical error shapes physicians' perceptions of
learning: an exploratory study.
August 21, 2019
Shepherd L, LaDonna KA, Cristancho SM, et al. How Medical Error Shapes Physicians' Perceptions of
Learning: An Exploratory Study. Acad Med. 2019;94(8):1157-1163. doi:10.1097/ACM.0000000000002752.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/45870/psn-pdf
March 25, 2017 - Improving communication with primary care physicians at
the time of hospital discharge.
March 25, 2017
Destino LA, Dixit A, Pantaleoni JL, et al. Improving Communication with Primary Care Physicians at the
Time of Hospital Discharge. Jt Comm J Qual Patient Saf. 2017;43(2):80-88. doi:10.1016/j.jcjq.2016.11.005.
htt…
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psnet.ahrq.gov/node/60176/psn-pdf
April 01, 2020 - Health and social care-associated harm amongst
vulnerable children in primary care: mixed methods
analysis of national safety reports.
April 1, 2020
Omar A, Rees P, Cooper A, et al. Health and social care-associated harm amongst vulnerable children in
primary care: mixed methods analysis of national safety reports…
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psnet.ahrq.gov/node/41661/psn-pdf
March 11, 2013 - 'Why is there another person's name on my infusion
bag?' Patient safety in chemotherapy care—a review of
the literature.
March 11, 2013
Kullberg A, Larsen J, Sharp L. 'Why is there another person's name on my infusion bag?' Patient safety in
chemotherapy care - a review of the literature. Eur J Oncol Nurs. 2013;17…
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psnet.ahrq.gov/node/44827/psn-pdf
February 14, 2017 - Using coworker observations to promote accountability
for disrespectful and unsafe behaviors by physicians and
advanced practice professionals.
February 14, 2017
Webb LE, Dmochowski RR, Moore IN, et al. Using Coworker Observations to Promote Accountability for
Disrespectful and Unsafe Behaviors by Physicians and A…
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psnet.ahrq.gov/node/866248/psn-pdf
July 10, 2024 - Did the organization of primary care practices during the
COVID-19 pandemic influence quality and safety? - an
international survey.
July 10, 2024
Eriksson M, Blomberg K, Arvidsson E, et al. Did the organization of primary care practices during the
COVID-19 pandemic influence quality and safety? – an international…
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psnet.ahrq.gov/node/40842/psn-pdf
September 24, 2016 - A systematic review of the psychological literature on
interruption and its patient safety implications.
September 24, 2016
Li SYW, Magrabi F, Coiera E. A systematic review of the psychological literature on interruption and its
patient safety implications. J Am Med Inform Assoc. 2012;19(1):6-12. doi:10.1136/amiajn…
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psnet.ahrq.gov/node/46679/psn-pdf
December 22, 2018 - Are parents who feel the need to watch over their
children's care better patient safety partners?
December 22, 2018
Cox E, Hansen K, Rajamanickam VP, et al. Are Parents Who Feel the Need to Watch Over Their
Children's Care Better Patient Safety Partners? Hosp Pediatr. 2017;7(12):716-722.
doi:10.1542/hpeds.2017-003…
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psnet.ahrq.gov/node/40910/psn-pdf
November 09, 2011 - The effect of hospital electronic health record adoption on
nurse-assessed quality of care and patient safety.
November 9, 2011
Kutney-Lee A, Kelly D. The effect of hospital electronic health record adoption on nurse-assessed quality of
care and patient safety. J Nurs Adm. 2011;41(11):466-72. doi:10.1097/NNA.0b013e…
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psnet.ahrq.gov/node/43851/psn-pdf
March 13, 2015 - Systematic review of the effectiveness of strategies to
encourage patients to remind healthcare professionals
about their hand hygiene.
March 13, 2015
Davis R, Parand A, Pinto A, et al. Systematic review of the effectiveness of strategies to encourage
patients to remind healthcare professionals about their hand hy…
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psnet.ahrq.gov/node/41522/psn-pdf
December 02, 2014 - Tenfold medication errors: 5 years' experience at a
university-affiliated pediatric hospital.
December 2, 2014
Doherty C, Donnell CM. Tenfold medication errors: 5 years' experience at a university-affiliated pediatric
hospital. Pediatrics. 2012;129(5):916-924. doi:10.1542/peds.2011-2526.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/49812/psn-pdf
November 01, 2017 - Specimen Almost Lost
November 1, 2017
Hehe YK. Specimen Almost Lost. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/specimen-almost-lost
The Case
A 29-year-old woman presented to the hospital with a rash that had spread across her legs and abdomen.
She was admitted to the medicine service for further evalu…
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psnet.ahrq.gov/node/49406/psn-pdf
June 01, 2003 - The Dangerous Detour
June 1, 2003
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dangerous-detour
The Case
Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service
for observation after being placed on a 72-hour hold by…
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psnet.ahrq.gov/node/49438/psn-pdf
March 05, 2004 - OR Peeping
March 1, 2004
Mackenzie CF. OR Peeping. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/or-peeping
The Case
A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete
spontaneous abortion (miscarriage).
At this community hospital, a new operating room (OR) su…
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psnet.ahrq.gov/node/33840/psn-pdf
August 01, 2017 - ACGME's 2017 Revision of Common Program
Requirements
August 1, 2017
Malloy K, Brigham TP, Nasca TJ. ACGME's 2017 Revision of Common Program Requirements. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/perspective/acgmes-2017-revision-common-program-requirements
Perspective
The Accreditation Council for Graduate …
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psnet.ahrq.gov/node/49487/psn-pdf
August 21, 2005 - Surprise Wire
August 21, 2005
Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/surprise-wire
The Case
A 39-year-old man with a history of liver disease presented to the emergency department (ED) with
gastrointestinal bleeding and altered mental status. Due to his clinic…
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psnet.ahrq.gov/innovation/critical-radiology-alert-process
November 16, 2022 - Critical Radiology Alert Process
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October 30, 2024
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March 01, 2008 - Hold That Order
March 1, 2008
Grissinger M. Hold That Order. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/hold-order
The Case
A 25-year-old woman with a history of a pituitary tumor was admitted with hypernatremia. Because of her
previous pituitary resection and radiation, the patient had a long history …