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psnet.ahrq.gov/web-mm/2-week-itch
June 16, 2019 - The 2-Week Itch
Citation Text:
Cohen MR. The 2-Week Itch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/852699/psn-pdf
August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety
August 30, 2023
Van CM, Mossburg S, McGaffigan P. Beyond the Pandemic: Creating Total Systems Safety. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
The COVID-19 pandemic necessitated a shift in operations …
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psnet.ahrq.gov/node/73229/psn-pdf
May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple
Health System Vulnerabilities
May 26, 2021
Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health
System Vulnerabilities. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…
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psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
December 18, 2019 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences
Citation Text:
Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…
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psnet.ahrq.gov/web-mm/raise-bar
May 29, 2024 - Raise the Bar
Citation Text:
Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
June 01, 2005 - Diagnostic Failure: The Growing Deficit
Citation Text:
Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/60722/psn-pdf
February 06, 2023 - Coronavirus Disease 2019 (COVID-19) and Diagnostic
Error
January 11, 2022
Desai AN, Romano PS. Coronavirus Disease 2019 (COVID-19) and Diagnostic Error. PSNet [internet].
2022.
https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
Originally published July 30, 2020. Updated January …
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psnet.ahrq.gov/node/840140/psn-pdf
January 01, 2023 - Implementation of the I-PASS handoff program in diverse
clinical environments: a multicenter prospective
effectiveness implementation study.
November 16, 2022
Starmer AJ, Spector ND, O'Toole JK, et al. Implementation of the I?PASS handoff program in diverse
clinical environments: a multicenter prospective effectiv…
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psnet.ahrq.gov/node/866731/psn-pdf
September 18, 2024 - Root cause analysis of cases involving diagnosis.
September 18, 2024
Graber ML, Castro GM, Danforth M, et al. Root cause analysis of cases involving diagnosis. Diagnosis
(Berl). 2024;11(4):353-368. doi:10.1515/dx-2024-0102.
https://psnet.ahrq.gov/issue/root-cause-analysis-cases-involving-diagnosis
Root cause analy…
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psnet.ahrq.gov/node/50942/psn-pdf
February 26, 2020 - Understanding the roles of three academic communities
in a prospective learning health ecosystem for diagnostic
excellence.
February 26, 2020
Satterfield K, Rubin JC, Yang D, et al. Understanding the roles of three academic communities in a
prospective learning health ecosystem for diagnostic excellence. Learn Hea…
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psnet.ahrq.gov/node/837972/psn-pdf
September 01, 2022 - Patient safety: where to aim when zero harm is not the
target-a case for learning and resilience.
September 1, 2022
Stockwell DC, Kayes DC, Thomas EJ. Patient safety: where to aim when zero harm is not the target-a case
for learning and resilience. J Patient Saf. 2022;18(5):e877-e882. doi:10.1097/pts.00000000000009…
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psnet.ahrq.gov/node/73211/psn-pdf
May 05, 2021 - The effectiveness of interruptive prescribing alerts in
ambulatory CPOE to change prescriber behaviour and
improve safety.
May 5, 2021
Cerqueira O, Gill M, Swar B, et al. The effectiveness of interruptive prescribing alerts in ambulatory CPOE
to change prescriber behaviour and improve safety. BMJ Qual Saf. 2021;30…
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psnet.ahrq.gov/node/861774/psn-pdf
January 31, 2024 - Grand rounds in methodology: key considerations for
implementing machine learning solutions in quality
improvement initiatives.
January 31, 2024
Verma AA, Trbovich PL, Mamdani MM, et al. Grand rounds in methodology: key considerations for
implementing machine learning solutions in quality improvement initiatives. …
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psnet.ahrq.gov/node/837143/psn-pdf
January 01, 2023 - Understanding the factors influencing implementation of
a new national patient safety policy in England: lessons
from 'Learning from Deaths'.
May 18, 2022
Lalani M, Morgan S, Basu A, et al. Understanding the factors influencing implementation of a new national
patient safety policy in England: lessons from ‘Learni…
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psnet.ahrq.gov/node/837502/psn-pdf
June 22, 2022 - Toward safer opioid prescribing in HIV care (TOWER): a
mixed-methods, cluster-randomized trial.
June 22, 2022
Cedillo G, George MC, Deshpande R, et al. Toward safer opioid prescribing in HIV care (TOWER): a
mixed-methods, cluster-randomized trial. Addict Sci Clin Pract. 2022;17(1):28. doi:10.1186/s13722-022-
00311…
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psnet.ahrq.gov/issue/center-consumer-health-care-information-patient-safety-center
February 04, 2025 - Multi-use Website
Center for Consumer Health Care Information Patient Safety Center.
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March 6, 2005
The Center's efforts for pati…
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psnet.ahrq.gov/node/867690/psn-pdf
March 05, 2025 - Trends of diagnostic adverse events in hospital deaths:
longitudinal analyses of four retrospective record review
studies.
March 5, 2025
Hooftman J, Zwaan L, Sikkens JJ, et al. Trends of diagnostic adverse events in hospital deaths:
longitudinal analyses of four retrospective record review studies. Diagnosis (Berl…
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psnet.ahrq.gov/node/867684/psn-pdf
March 05, 2025 - Development of a preliminary patient safety classification
system for generative AI.
March 5, 2025
Hose B-Z, Handley JL, Biro J, et al. Development of a preliminary patient safety classification system for
generative AI. BMJ Qual Saf. 2025;34(2):130-132. doi:10.1136/bmjqs-2024-017918.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/867691/psn-pdf
March 05, 2025 - Surgeon perception and attitude towards the moral
imperative of institutionally addressing second-victim
syndrome in surgery.
March 5, 2025
Hsiao L-H, Kopar PK. Surgeon perception and attitude towards the moral imperative of institutionally
addressing second-victim syndrome in surgery. J Am Coll Surg. 2025;240(2):…
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psnet.ahrq.gov/node/60644/psn-pdf
July 01, 2020 - Adverse events and burnout: the moderating effects of
workgroup identification and safety climate.
July 1, 2020
Vogus TJ, Ramanujam R, Novikov Z, et al. Adverse events and burnout: the moderating effects of
workgroup identification and safety climate. Med Care. 2020;58(7):594-600.
doi:10.1097/mlr.0000000000001341.…