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psnet.ahrq.gov/node/48084/psn-pdf
August 14, 2019 - Electronic health records, communication, and data
sharing: challenges and opportunities for improving the
diagnostic process.
August 14, 2019
Quinn M, Forman J, Harrod M, et al. Electronic health records, communication, and data sharing:
challenges and opportunities for improving the diagnostic process. Diagnosis…
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psnet.ahrq.gov/node/44813/psn-pdf
February 15, 2017 - Remote video auditing with real-time feedback in an
academic surgical suite improves safety and efficiency
metrics: a cluster randomised study.
February 15, 2017
Overdyk FJ, Dowling O, Newman S, et al. Remote video auditing with real-time feedback in an academic
surgical suite improves safety and efficiency metric…
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psnet.ahrq.gov/node/44721/psn-pdf
August 20, 2016 - Tall Man lettering and potential prescription errors: a time
series analysis of 42 children's hospitals in the USA over
9 years.
August 20, 2016
Zhong W, Feinstein JA, Patel NS, et al. Tall Man lettering and potential prescription errors: a time series
analysis of 42 children's hospitals in the USA over 9 years. B…
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psnet.ahrq.gov/node/47228/psn-pdf
August 09, 2018 - A road map for advancing the practice of respect in health
care: the results of an interdisciplinary modified Delphi
consensus study.
August 9, 2018
Sokol-Hessner L, Folcarelli P, Annas CL, et al. A Road Map for Advancing the Practice of Respect in
Health Care: The Results of an Interdisciplinary Modified Delphi C…
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psnet.ahrq.gov/node/38289/psn-pdf
July 05, 2008 - Resident Duty Hours: Enhancing Sleep, Supervision, and
Safety.
July 5, 2008
Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident)
Hours and Work Schedule to Improve Patient Safety, Institute of Medicine. Washington, DC: The National
Academies Press; 2008. ISBN: 97803091277…
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psnet.ahrq.gov/node/43865/psn-pdf
May 01, 2015 - Computerised physician order entry-related medication
errors: analysis of reported errors and vulnerability
testing of current systems.
May 1, 2015
Schiff GD, Amato MG, Eguale T, et al. Computerised physician order entry-related medication errors:
analysis of reported errors and vulnerability testing of current sy…
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psnet.ahrq.gov/node/37978/psn-pdf
April 11, 2011 - Effects of the Accreditation Council for Graduate Medical
Education duty hour limits on sleep, work hours, and
safety.
April 11, 2011
Landrigan CP, Fahrenkopf AM, Lewin D, et al. Effects of the accreditation council for graduate medical
education duty hour limits on sleep, work hours, and safety. Pediatrics. 2008;…
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psnet.ahrq.gov/node/47437/psn-pdf
November 02, 2018 - Engaging hospital patients in the medication
reconciliation process using tablet computers.
November 2, 2018
Prey JE, Polubriaginof F, Grossman L, et al. Engaging hospital patients in the medication reconciliation
process using tablet computers. J Am Med Inform Assoc. 2018;25(11):1460-1469.
doi:10.1093/jamia/ocy11…
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psnet.ahrq.gov/node/39948/psn-pdf
December 21, 2014 - Wrong-site and wrong-patient procedures in the Universal
Protocol era: analysis of a prospective database of
physician self-reported occurrences.
December 21, 2014
Stahel PF, Sabel A, Victoroff MS, et al. Wrong-site and wrong-patient procedures in the universal protocol
era: analysis of a prospective database of p…
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psnet.ahrq.gov/node/42510/psn-pdf
August 21, 2013 - Root cause analysis reports help identify common factors
in delayed diagnosis and treatment of outpatients.
August 21, 2013
Giardina TD, King BJ, Ignaczak AP, et al. Root cause analysis reports help identify common factors in
delayed diagnosis and treatment of outpatients. Health Aff (Millwood). 2013;32(8):1368-75.…
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psnet.ahrq.gov/issue/patient-safety-10
May 01, 2023 - Multi-use Website
Patient Safety.
Citation Text:
Patient Safety. Minnesota Hospital Association; MHA.
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psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
September 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
Citation Text:
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. 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/33563/psn-pdf
September 16, 2024 - Culture of Safety
September 16, 2024
Culture of Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/culture-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in …
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psnet.ahrq.gov/sites/default/files/2020-01/final_spotlight_near_miss_transfusion_01082020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
“This is the wrong patient’s blood!”:
Evaluating a Near-Miss Wrong
Transfusion Event
Source and Credits
• This presentation is based on the January 2020 AHRQ WebM&M
Spotlight Case
• Commentary by: Sarah Barnhard MD
o Medical Director of Transfusion Services at UC-Davis Health
o Editors in …
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psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
May 01, 2007 - In Conversation with...Sir Liam Donaldson, MD, MSc
May 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..Sir Liam Donaldson, MD, MSc. PSNet [internet]. 2007.In Conversation with...Sir Liam Donaldson, MD, MSc. PSNet [internet]. Rockville (MD): Agency…
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psnet.ahrq.gov/issue/rxawareness
September 07, 2016 - Multi-use Website
RxAwareness.
Citation Text:
RxAwareness. Centers for Disease Control and Prevention; CDC.
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psnet.ahrq.gov/issue/when-bullying-affects-patient-safety
March 13, 2019 - Commentary
When bullying affects patient safety.
Citation Text:
When Bullying Affects Patient Safety. AORN J. 2018;108(1):78-80. doi:10.1002/aorn.12294.
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DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/issue/doctors-learn-say-im-sorry
August 17, 2016 - Newspaper/Magazine Article
Doctors learn to say 'I'm Sorry.'
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May 4, 2015
View more articles from the same authors.
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psnet.ahrq.gov/issue/patient-safety-resource-centre
May 12, 2021 - Multi-use Website
Patient Safety Resource Centre.
Citation Text:
Patient Safety Resource Centre. The Health Foundation.
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psnet.ahrq.gov/node/47008/psn-pdf
October 13, 2018 - Impact of a commercial order entry system on prescribing
errors amenable to computerised decision support in the
hospital setting: a prospective pre–post study.
October 13, 2018
Pontefract SK, Hodson J, Slee A, et al. Impact of a commercial order entry system on prescribing errors
amenable to computerised decision…