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psnet.ahrq.gov/issue/potential-safety-gaps-order-entry-and-automated-drug-alerts-nationwide-survey-va-physician
March 10, 2011 - Study
Potential safety gaps in order entry and automated drug alerts: a nationwide survey of VA physician self-reported practices with computerized order entry.
Citation Text:
Spina JR, Glassman PA, Simon B, et al. Potential safety gaps in order entry and automated drug alerts: a natio…
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psnet.ahrq.gov/issue/well-defined-pediatric-icu-active-surveillance-using-nonmedical-personnel-capture-less
July 13, 2010 - Study
The well-defined pediatric ICU: active surveillance using nonmedical personnel to capture less serious safety events.
Citation Text:
White WA, Kennedy K, Belgum HS, et al. The Well-Defined Pediatric ICU: Active Surveillance Using Nonmedical Personnel to Capture Less Serious Safety …
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psnet.ahrq.gov/issue/primary-care-physicians-willingness-disclose-oncology-errors-involving-multiple-providers
July 28, 2014 - Study
Primary care physicians' willingness to disclose oncology errors involving multiple providers to patients.
Citation Text:
Mazor KM, Roblin DW, Greene SM, et al. Primary care physicians' willingness to disclose oncology errors involving multiple providers to patients. BMJ Qual Saf. …
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psnet.ahrq.gov/issue/understanding-differences-electronic-health-record-ehr-use-linking-individual-physicians
November 17, 2015 - Study
Understanding differences in electronic health record (EHR) use: linking individual physicians' perceptions of uncertainty and EHR use patterns in ambulatory care.
Citation Text:
Lanham HJ, Sittig DF, Leykum LK, et al. Understanding differences in electronic health record (EHR) u…
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psnet.ahrq.gov/issue/hospital-staff-should-use-more-one-method-detect-adverse-events-and-potential-adverse-events
November 12, 2014 - Study
Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place.
Citation Text:
Olsen S, Neale G, Schwab K, et al. Hospital staff should use mo…
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psnet.ahrq.gov/issue/providing-feedback-following-leadership-walkrounds-associated-better-patient-safety-culture
February 01, 2023 - Study
Classic
Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout.
Citation Text:
Sexton B, Adair KC, Leonard MW, et al. Providing feedback following Leadership WalkRou…
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psnet.ahrq.gov/issue/situ-simulation-tool-longitudinally-identify-and-track-latent-safety-threats-structured
June 08, 2022 - Study
In situ simulation as a tool to longitudinally identify and track latent safety threats in a structured quality improvement initiative for SARS-CoV-2 airway management: a single-center study.
Citation Text:
Jafri FN, Yang CJ, Kumar A, et al. In situ simulation as a tool to longitud…
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psnet.ahrq.gov/issue/distinguishing-high-performing-low-performing-hospitals-severe-maternal-morbidity-focus
June 01, 2022 - Study
Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on quality and equity.
Citation Text:
Howell EA, Sofaer S, Balbierz A, et al. Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on q…
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psnet.ahrq.gov/issue/impact-commercial-order-entry-system-prescribing-errors-amenable-computerised-decision
December 21, 2022 - Study
Impact of a commercial order entry system on prescribing errors amenable to computerised decision support in the hospital setting: a prospective pre–post study.
Citation Text:
Pontefract SK, Hodson J, Slee A, et al. Impact of a commercial order entry system on prescribing errors am…
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psnet.ahrq.gov/issue/electronic-health-record-based-real-time-analytics-program-patient-safety-surveillance-and
May 19, 2018 - Study
An electronic health record–based real-time analytics program for patient safety surveillance and improvement.
Citation Text:
Classen D, Li M, Miller S, et al. An Electronic Health Record-Based Real-Time Analytics Program For Patient Safety Surveillance And Improvement. Health Aff …
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psnet.ahrq.gov/node/33782/psn-pdf
March 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety
Measurement Program?
March 1, 2015
Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? PSNet [internet].
2015.
https://psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
Perspective
Much…
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psnet.ahrq.gov/node/49397/psn-pdf
May 01, 2003 - The Dropped Lung
May 1, 2003
Heffner JR. The Dropped Lung. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dropped-lung
The Case
A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been
hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…
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psnet.ahrq.gov/node/49604/psn-pdf
June 01, 2010 - Tacit Handover, Overt Mishap
June 1, 2010
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
The Case
A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3
years earlier to treat an abdo…
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - Patient Safety 101
Citation Text:
Patient Safety 101. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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D…
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - residents remember the key elements of the handoff process that the literature suggested were essential for reliable
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - In general, radiographic confirmation of catheter location is reliable.
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psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
December 07, 2009 - The National Committee for Quality Assurance (NCQA) includes implementation of reliable systems to effectively
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psnet.ahrq.gov/node/49729/psn-pdf
April 01, 2015 - several studies have attempted to risk stratify patients with potential aortic dissection (3,17), no
reliable
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psnet.ahrq.gov/web-mm/blind-spot
July 30, 2020 - with ophthalmologic consultation if symptoms persist once the patient is alert and able to provide a reliable
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psnet.ahrq.gov/node/50611/psn-pdf
October 30, 2019 - However, without well-designed and rigorously tested systems that include effective
feedback loops, reliable