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psnet.ahrq.gov/node/45082/psn-pdf
April 27, 2016 - Surgeons must tell patients of double-booked surgeries,
new guidelines say.
April 27, 2016
Abelson J, Staltzman J. Boston Globe. April 13, 2016.
https://psnet.ahrq.gov/issue/surgeons-must-tell-patients-double-booked-surgeries-new-guidelines-say
Although scheduling overlapping surgeries may improve operating room e…
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psnet.ahrq.gov/node/45332/psn-pdf
August 27, 2018 - Guideline implementation: prevention of retained surgical
items.
August 27, 2018
Fencl JL. Guideline Implementation: Prevention of Retained Surgical Items. AORN J. 2016;104(1):37-48.
doi:10.1016/j.aorn.2016.05.005.
https://psnet.ahrq.gov/issue/guideline-implementation-prevention-retained-surgical-items
Although i…
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psnet.ahrq.gov/node/43333/psn-pdf
January 15, 2017 - A multidisciplinary, multifaceted improvement initiative to
eliminate mislabelled laboratory specimens at a large
tertiary care hospital.
January 15, 2017
Seferian EG, Jamal S, Clark K, et al. A multidisciplinary, multifaceted improvement initiative to eliminate
mislabelled laboratory specimens at a large tertiary…
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psnet.ahrq.gov/node/37336/psn-pdf
January 05, 2012 - 'My five moments for hand hygiene': a user-centred
design approach to understand, train, monitor and report
hand hygiene.
January 5, 2012
Sax H, Allegranzi B, Uçkay I, et al. 'My five moments for hand hygiene': a user-centred design approach to
understand, train, monitor and report hand hygiene. J Hosp Infect. 200…
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psnet.ahrq.gov/node/38777/psn-pdf
March 04, 2011 - Perceptions of standards-based electronic prescribing
systems as implemented in outpatient primary care: a
physician survey.
March 4, 2011
Wang J, Patel MH, Schueth AJ, et al. Perceptions of standards-based electronic prescribing systems as
implemented in outpatient primary care: a physician survey. J Am Med Infor…
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psnet.ahrq.gov/node/37879/psn-pdf
July 02, 2008 - Work hour rules and contributors to patient care
mistakes: a focus group study with internal medicine
residents.
July 2, 2008
Fletcher KE, Parekh V, Halasyamani L, et al. Work hour rules and contributors to patient care mistakes: a
focus group study with internal medicine residents. J Hosp Med. 2008;3(3):228-37. d…
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psnet.ahrq.gov/node/842434/psn-pdf
June 01, 2024 - AHRQ Safety Program for Telemedicine.
January 22, 2024
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/ahrq-safety-program-telemedicine
Telemedicine efforts harbor both risk and reward to patients and clinicians. The AHRQ Safety Program for
Telemedicine is a national effort to develop and …
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psnet.ahrq.gov/node/45010/psn-pdf
March 30, 2016 - Most dangerous time at the hospital? It may be when you
leave.
March 30, 2016
Khullar D. New York Times. March 17, 2016.
https://psnet.ahrq.gov/issue/most-dangerous-time-hospital-it-may-be-when-you-leave
Preventing readmissions after hospital discharge is a national policy priority. This newspaper article
discuss…
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psnet.ahrq.gov/node/73911/psn-pdf
October 06, 2021 - Misdiagnosis of acute myocardial infarction: a systematic
review of the literature.
October 6, 2021
Kwok CS, Bennett S, Azam Z, et al. Misdiagnosis of acute myocardial infarction: a systematic review of the
literature. Crit Pathw Cardiol. 2021;20(3):155-162. doi:10.1097/hpc.0000000000000256.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/853058/psn-pdf
August 30, 2023 - Diagnostic reliability in teledermatology: a systematic
review and a meta-analysis.
August 30, 2023
Bourkas AN, Barone N, Bourkas MEC, et al. Diagnostic reliability in teledermatology: a systematic review
and a meta-analysis. BMJ Open. 2023;13(8):e068207. doi:10.1136/bmjopen-2022-068207.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/43164/psn-pdf
May 03, 2016 - Patient safety in the era of healthcare reform.
May 3, 2016
Leape L. Patient safety in the era of healthcare reform. Clin Orthop Relat Res. 2015;473(5):1568-73.
doi:10.1007/s11999-014-3598-6.
https://psnet.ahrq.gov/issue/patient-safety-era-healthcare-reform
The publication of To Err Is Human spurred efforts to imp…
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psnet.ahrq.gov/node/849133/psn-pdf
May 17, 2023 - The association between patient safety culture and
adverse events - a scoping review.
May 17, 2023
Vikan M, Haugen AS, Bjørnnes AK, et al. The association between patient safety culture and adverse
events – a scoping review. BMC Health Serv Res. 2023;23(1):300. doi:10.1186/s12913-023-09332-8.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/43465/psn-pdf
February 18, 2015 - Hospital Readmissions Reduction Program: implications
for pharmacy.
February 18, 2015
Boesen KAG, Leal S, Sheehan VC, et al. Hospital Readmissions Reduction Program: implications for
pharmacy. Am J Health Syst Pharm. 2015;72(3):237-44. doi:10.2146/ajhp140177.
https://psnet.ahrq.gov/issue/hospital-readmissions-redu…
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psnet.ahrq.gov/node/73476/psn-pdf
July 07, 2021 - The role of apology laws in medical malpractice.
July 7, 2021
Ross NE, Newman WJ. J Am Acad Psychiatry Law. 2021;49(3):406-414.
https://psnet.ahrq.gov/issue/role-apology-laws-medical-malpractice
Open disclosure of errors and adverse events is increasingly encouraged in healthcare, but clinicians
frequently ci…
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psnet.ahrq.gov/node/849336/psn-pdf
May 24, 2023 - AI may be on its way to your doctor’s office, but it’s not
ready to see patients.
May 24, 2023
Tahir D. KFF Health News. May 12, 2023.
https://psnet.ahrq.gov/issue/ai-may-be-its-way-your-doctors-office-its-not-ready-see-patients
Real-time use of artificial intelligence (AI) in health care settings continues to cau…
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psnet.ahrq.gov/node/851204/psn-pdf
July 05, 2023 - Drugmakers are abandoning cheap generics, and now US
cancer patients can’t get meds.
July 5, 2023
Allen A. KFF Health News. June 21, 2023.
https://psnet.ahrq.gov/issue/drugmakers-are-abandoning-cheap-generics-and-now-us-cancer-patients-
cant-get-meds
A variety of supply-chain, quality control, and economic factor…
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psnet.ahrq.gov/node/44940/psn-pdf
September 20, 2016 - Dual-process cognitive interventions to enhance
diagnostic reasoning: a systematic review.
September 20, 2016
Lambe KA, O'Reilly G, Kelly BD, et al. Dual-process cognitive interventions to enhance diagnostic
reasoning: a systematic review. BMJ Qual Saf. 2016;25(10):808-820. doi:10.1136/bmjqs-2015-004417.
https://p…
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psnet.ahrq.gov/node/43811/psn-pdf
July 18, 2018 - 2014 Annual Benchmarking Report: Malpractice Risks in
the Diagnostic Process.
July 18, 2018
Hoffman J, ed. Cambridge, MA: CRICO Strategies; 2014.
https://psnet.ahrq.gov/issue/2014-annual-benchmarking-report-malpractice-risks-diagnostic-process
This analysis of more than 4700 diagnosis-related malpractice claims fo…
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psnet.ahrq.gov/node/41653/psn-pdf
December 30, 2014 - Impact of a hospital-wide hand hygiene initiative on
healthcare-associated infections: results of an interrupted
time series.
December 30, 2014
Kirkland KB, Homa KA, Lasky RA, et al. Impact of a hospital-wide hand hygiene initiative on healthcare-
associated infections: results of an interrupted time series. BMJ Q…
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psnet.ahrq.gov/node/47459/psn-pdf
October 10, 2018 - People, processes, health IT and accurate patient
identification.
October 10, 2018
Quick Safety. October 1, 2018;(45):1-2.
https://psnet.ahrq.gov/issue/people-processes-health-it-and-accurate-patient-identification
This newsletter article reviews common problems related to patient identification and recommends
st…