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psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose
Citation Text:
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/issue/can-patient-safety-be-measured-surveys-patient-experiences
March 04, 2020 - Study
Can patient safety be measured by surveys of patient experiences?
Citation Text:
Solberg LI, Asche SE, Averbeck BM, et al. Can patient safety be measured by surveys of patient experiences? Jt Comm J Qual Patient Saf. 2008;34(5):266-274.
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psnet.ahrq.gov/issue/educational-targets-reduce-medication-errors-general-surgery-residents
October 19, 2022 - Study
Educational targets to reduce medication errors by general surgery residents.
Citation Text:
Chaitoff A, Strong AT, Bauer SR, et al. Educational Targets to Reduce Medication Errors by General Surgery Residents. J Surg Educ. 2019;76(6):1612-1621. doi:10.1016/j.jsurg.2019.04.009.
C…
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psnet.ahrq.gov/issue/assessing-national-electronic-injury-surveillance-system-cooperative-adverse-drug-event
February 27, 2019 - Government Resource
Assessing the National Electronic Injury Surveillance System—Cooperative Adverse Drug Event Surveillance Project—six sites, United States, January 1–June 15, 2004.
Citation Text:
Prevention C for DC and. Assessing the National Electronic Injury Surveillance System-C…
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psnet.ahrq.gov/issue/physician-evaluation-after-medical-errors-does-having-computer-decision-aid-help-or-hurt
May 19, 2021 - Study
Physician evaluation after medical errors: does having a computer decision aid help or hurt in hindsight?
Citation Text:
Pezzo M, Pezzo SP. Physician evaluation after medical errors: does having a computer decision aid help or hurt in hindsight? Med Decis Making. 2006;26(1):48-56…
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psnet.ahrq.gov/node/34135/psn-pdf
February 28, 2024 - Hand Hygiene in Healthcare Settings.
February 28, 2024
Centers for Disease Control and Prevention
https://psnet.ahrq.gov/issue/hand-hygiene-healthcare-settings
The hand hygiene guidelines represent part of a U.S. Centers for Disease Control and Prevention (CDC)
strategy to promote patient safety by reducing infect…
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psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
February 01, 2011 - A UT CS&E Steering Committee with representatives from each campus was established to provide oversight
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psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
April 09, 2014 - We can't get along without each other": qualitative interviews with physicians about device industry representatives
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psnet.ahrq.gov/node/35318/psn-pdf
September 20, 2024 - AHRQ Quality Indicators.
September 20, 2024
Agency for Healthcare Research and Quality
https://psnet.ahrq.gov/issue/ahrq-quality-indicators
The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QIs) represent quality
measures that make use of a hospital's available administrative data to inform…
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psnet.ahrq.gov/issue/national-scorecard-rates-hospital-acquired-conditions-2010-2015-interim-data-national-efforts
December 24, 2008 - Book/Report
National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer.
Citation Text:
National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health C…
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psnet.ahrq.gov/node/863762/psn-pdf
March 14, 2024 - Diagnostic Excellence: a Patient Safety Awareness Week
Webinar.
March 6, 2024
Institute for Healthcare Improvement. March 14, 2024.
https://psnet.ahrq.gov/issue/diagnostic-excellence-patient-safety-awareness-week-webinar
Diagnostic safety is core to care without harm. This webinar aligned with the 2024 Patient Saf…
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psnet.ahrq.gov/node/49552/psn-pdf
January 01, 2008 - How Do Providers Recover From Errors?
January 1, 2008
West CP. How Do Providers Recover From Errors? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
Case Objectives
Describe the provider-specific prevalence of medical errors.
Appreciate the impact of medical errors on care pr…
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psnet.ahrq.gov/node/49480/psn-pdf
May 01, 2005 - Diagnosing Diagnostic Mistakes
May 1, 2005
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
Learning Objectives
Understand the biases that may contribute to overcalling medical errors
Describe the impact of conside…
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psnet.ahrq.gov/node/33702/psn-pdf
November 01, 2010 - In Conversation with...Patrick S. Romano, MD, MPH
November 1, 2010
In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
Editor's note: Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the Universit…
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psnet.ahrq.gov/node/836892/psn-pdf
April 07, 2022 - emergency medicine director of operations, the ED
clinical nurse specialist, ED nurse manager, and ad hoc representatives
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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - Based on their
presentations at an AHRQ annual meeting, we spoke with representatives from two PSOs,
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psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - A couple of the key departments did not send representatives
and one member of the night staff was not
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psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - To prepare this updated summary, the Editorial Team worked closely with representatives associated with
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psnet.ahrq.gov/issue/investigating-association-alerts-national-mortality-surveillance-system-subsequent-hospital
October 20, 2021 - Study
Investigating the association of alerts from a national mortality surveillance system with subsequent hospital mortality in England: an interrupted time series analysis.
Citation Text:
Cecil E, Bottle A, Esmail A, et al. Investigating the association of alerts from a national morta…
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psnet.ahrq.gov/node/49818/psn-pdf
January 01, 2018 - A Costly Colonoscopy Leads to a Delay in Diagnosis
January 1, 2018
Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
The Case
A 50-year-old man presented to a primary care clinic to establish care, as he ha…