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psnet.ahrq.gov/node/35207/psn-pdf
December 19, 2009 - Patient safety concerns arising from test results that
return after hospital discharge.
December 19, 2009
Roy CL, Poon EG, Karson A, et al. Patient safety concerns arising from test results that return after hospital
discharge. Ann Intern Med. 2005;143(2):121-128.
https://psnet.ahrq.gov/issue/patient-safety-concer…
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psnet.ahrq.gov/node/46249/psn-pdf
July 12, 2017 - Zero preventable deaths after traumatic injury: an
achievable goal.
July 12, 2017
Spinella PC. Zero preventable deaths after traumatic injury. J Trauma Acute Care Surg. 2017;82:S2-S8.
doi:10.1097/ta.0000000000001425.
https://psnet.ahrq.gov/issue/zero-preventable-deaths-after-traumatic-injury-achievable-goal
Criti…
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psnet.ahrq.gov/node/43860/psn-pdf
March 25, 2015 - Pharmacy dispensing errors: claims study emphasizes
need for systematic vigilance.
March 25, 2015
Webb J. Drug Topics. March 10, 2015.
https://psnet.ahrq.gov/issue/pharmacy-dispensing-errors-claims-study-emphasizes-need-systematic-
vigilance
Pharmacies can serve as gatekeepers to ensure patients receive the corre…
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psnet.ahrq.gov/node/46154/psn-pdf
June 07, 2017 - Postoperative opioid prescribing and the pain scores on
Hospital Consumer Assessment of Healthcare Providers
and Systems survey.
June 7, 2017
Lee JS, Hu HM, Brummett CM, et al. Postoperative Opioid Prescribing and the Pain Scores on Hospital
Consumer Assessment of Healthcare Providers and Systems Survey. JAMA. 201…
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psnet.ahrq.gov/node/44368/psn-pdf
September 29, 2017 - A systematic review of the effect of distraction on
surgeon performance: directions for operating room
policy and surgical training.
September 29, 2017
Mentis HM, Chellali A, Manser K, et al. A systematic review of the effect of distraction on surgeon
performance: directions for operating room policy and surgical …
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psnet.ahrq.gov/node/838922/psn-pdf
October 26, 2022 - Effect of pharmacist email alerts on concurrent
prescribing of opioids and benzodiazepines by
prescribers and primary care managers: a randomized
clinical trial.
October 26, 2022
Sacarny A, Safran E, Steffel M, et al. Effect of pharmacist email alerts on concurrent prescribing of opioids
and benzodiazepines by pr…
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psnet.ahrq.gov/node/46247/psn-pdf
August 08, 2018 - Distractions in the anesthesia work environment: impact
on patient safety? Report of a meeting sponsored by the
Anesthesia Patient Safety Foundation.
August 8, 2018
van Pelt M, Weinger MB. Distractions in the Anesthesia Work Environment: Impact on Patient Safety?
Report of a Meeting Sponsored by the Anesthesia Pat…
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psnet.ahrq.gov/node/47869/psn-pdf
April 17, 2019 - Minimizing Opioid Prescribing in Surgery (MOPiS)
initiative: an analysis of implementation barriers.
April 17, 2019
Coughlin JM, Shallcross ML, Schäfer WLA, et al. Minimizing Opioid Prescribing in Surgery (MOPiS)
Initiative: An Analysis of Implementation Barriers. J Surg Res. 2019;239:309-319.
doi:10.1016/j.jss.20…
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psnet.ahrq.gov/node/73956/psn-pdf
October 13, 2021 - Acute care nurses' perceptions of leadership, teamwork,
turnover intention and patient safety - a mixed methods
study.
October 13, 2021
Zaheer S, Ginsburg LR, Wong HJ, et al. Acute care nurses’ perceptions of leadership, teamwork, turnover
intention and patient safety – a mixed methods study. BMC Nurs. 2021;20(1):…
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psnet.ahrq.gov/node/865659/psn-pdf
April 24, 2024 - Diagnostic error in mental health: a review.
April 24, 2024
Bradford A, Meyer AND, Khan S, et al. Diagnostic error in mental health: a review. BMJ Qual Saf.
2024;33(10):663-672. doi:10.1136/bmjqs-2023-016996.
https://psnet.ahrq.gov/issue/diagnostic-error-mental-health-review
Diagnostic errors in mental health diso…
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psnet.ahrq.gov/node/73069/psn-pdf
March 24, 2021 - Evaluation of the quality of 'do not use' medication
abbreviation audits: a key enabler to successful
implementation of audit and feedback.
March 24, 2021
Li E, Marrandino J, Marshall S, et al. Evaluation of the quality of ‘do not use’ medication abbreviation
audits: a key enabler to successful implementation of a…
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psnet.ahrq.gov/node/37430/psn-pdf
February 01, 2011 - Nonpayment for harms resulting from medical care:
catheter-associated urinary tract infections.
February 1, 2011
Wald HL, Kramer AM. Nonpayment for harms resulting from medical care: catheter-associated urinary tract
infections. JAMA. 2007;298(23):2782-4. doi:10.1001/jama.298.23.2782.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/50916/psn-pdf
February 19, 2020 - Patient safety and suicide prevention in mental health
services: time for a new paradigm?
February 19, 2020
Quinlivan L, Littlewood DL, Webb RT, et al. Patient safety and suicide prevention in mental health services:
time for a new paradigm? J Mental Health. 2020;29(1):1-5. doi:10.1080/09638237.2020.1714013.
https…
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psnet.ahrq.gov/node/50416/psn-pdf
September 04, 2019 - Perceptual and interpretive error in diagnostic
radiology—causes and potential solutions.
September 4, 2019
Degnan AJ, Ghobadi EH, Hardy P, et al. Perceptual and Interpretive Error in Diagnostic Radiology-Causes
and Potential Solutions. Acad Radiol. 2019;26(6):833-845. doi:10.1016/j.acra.2018.11.006.
https://psnet…
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psnet.ahrq.gov/node/44801/psn-pdf
June 22, 2016 - Safety for all: integrated design for inpatient units.
June 22, 2016
Hunt JM, Sine DM. Patient Saf Qual Healthc. May/June 2016;13:20-28.
https://psnet.ahrq.gov/issue/safety-all-integrated-design-inpatient-units
Design is emerging as an important tactic to augment safe care delivery. Hospitals that provide care for
…
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psnet.ahrq.gov/node/47278/psn-pdf
August 15, 2018 - Drawing boundaries: the difficulty in defining clinical
reasoning.
August 15, 2018
Young M, Thomas A, Lubarsky S, et al. Drawing Boundaries: The Difficulty in Defining Clinical Reasoning.
Acad Med. 2018;93(7):990-995. doi:10.1097/ACM.0000000000002142.
https://psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defi…
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psnet.ahrq.gov/node/73352/psn-pdf
June 02, 2021 - Improving diagnosis by feedback and deliberate practice:
one-on-one coaching for diagnostic maturation.
June 2, 2021
Sinha P, Pischel L, Sofair AN. Improving diagnosis by feedback and deliberate practice: one-on-one
coaching for diagnostic maturation. Diagnosis (Berl). 2021;8(2):157-160. doi:10.1515/dx-2020-0129.
…
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psnet.ahrq.gov/node/50932/psn-pdf
February 26, 2020 - Clinician-directed performance improvement: moving
beyond externally mandated metrics.
February 26, 2020
Goitein L. Clinician-directed performance improvement: moving beyond externally mandated metrics.
Health Aff (Millwood). 2020;39(2). doi:10.1377/hlthaff.2019.00505.
https://psnet.ahrq.gov/issue/clinician-direct…
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psnet.ahrq.gov/node/46473/psn-pdf
December 18, 2017 - Diagnostic errors: impact of an educational intervention
on pediatric primary care.
December 18, 2017
Walsh JN, Knight M, Lee AJ. Diagnostic Errors: Impact of an Educational Intervention on Pediatric Primary
Care. Journal of Pediatric Health Care. 2017;32(1). doi:10.1016/j.pedhc.2017.07.004.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/45823/psn-pdf
May 09, 2017 - The effect of prescriber education on medication-related
patient harm in the hospital: a systematic review.
May 9, 2017
Bos JM, van den Bemt PMLA, de Smet PAGM, et al. The effect of prescriber education on medication-
related patient harm in the hospital: a systematic review. Br J Clin Pharmacol. 2017;83(5):953-961…