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  1. psnet.ahrq.gov/issue/performance-trigger-tool-identifying-adverse-events-oncology
    May 23, 2018 - Study Performance of a trigger tool for identifying adverse events in oncology. Citation Text: Lipitz-Snyderman A, Classen D, Pfister D, et al. Performance of a Trigger Tool for Identifying Adverse Events in Oncology. J Oncol Pract. 2017;13(3). doi:10.1200/jop.2016.016634. Copy Citatio…
  2. psnet.ahrq.gov/issue/community-pharmacy-survey-patient-safety-culture-2015-user-comparative-database-report
    November 30, 2016 - Book/Report Community Pharmacy Survey on Patient Safety Culture 2015 User Comparative Database Report. Citation Text: Community Pharmacy Survey on Patient Safety Culture 2015 User Comparative Database Report. Famolaro T, Yount N, Sorra J, et al. Rockville, MD: Agency for Healthcare Resea…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60035/psn-pdf
    September 22, 2023 - SOPS Medical Office Database. March 11, 2020 Agency for Healthcare Research and Quality (AHRQ). March 2020. https://psnet.ahrq.gov/issue/sops-medical-office-database This website provides a report and data repository representing medical offices that administered the AHRQ Surveys on Patient Safety Culture™ (SOPS®)…
  4. psnet.ahrq.gov/issue/reasons-computerised-provider-order-entry-cpoe-based-inpatient-medication-ordering-errors
    June 27, 2018 - Study Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders. Citation Text: Abraham J, Kannampallil TG, Jarman A, et al. Reasons for computerised provider order entry (CPOE)-based inpatient medication orde…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50719/psn-pdf
    December 04, 2019 - A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! December 4, 2019 ISMP Medication Safety Alert! Acute Care Edition. November 7, 2019 https://psnet.ahrq.gov/issue/lot-happens-when-you-report-hazard-or-error-ismp-theres-no-black-hole-here The reporting and analysis of incidents i…
  6. psnet.ahrq.gov/primer/triggers-and-trigger-tools
    September 15, 2024 - Triggers and Trigger Tools Citation Text: Triggers and Trigger Tools. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
  7. psnet.ahrq.gov/web-mm/consequences-medical-overuse
    May 05, 2021 - SPOTLIGHT CASE Consequences of Medical Overuse Citation Text: Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibT…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47621/psn-pdf
    May 11, 2019 - 2018 update on pediatric medical overuse: a review. May 11, 2019 Coon ER, Quinonez RA, Morgan DJ, et al. 2018 Update on Pediatric Medical Overuse: A Review. JAMA Pediatr. 2019;173(4):379-384. doi:10.1001/jamapediatrics.2018.5550. https://psnet.ahrq.gov/issue/2018-update-pediatric-medical-overuse-review Overuse of …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843091/psn-pdf
    January 25, 2023 - Anesthesia outside of the OR: cause for patient safety concerns? January 25, 2023 DePeau-Wilson M. MedPage Today. January 13, 2023. https://psnet.ahrq.gov/issue/anesthesia-outside-or-cause-patient-safety-concerns The use of anesthesia in ambulatory settings presents both advantage and risk to patients and clinicia…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73572/psn-pdf
    August 04, 2021 - Center for Innovations in Quality, Effectiveness and Safety. IQuESt! August 4, 2021 Houston, TX:  Baylor College of Medicine. https://psnet.ahrq.gov/issue/center-innovations-quality-effectiveness-and-safety-iquest This Center represents a partnership with the Veterans Affairs Health Services Research & Develo…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854634/psn-pdf
    January 01, 2024 - Elopement: evidence-based mitigation and management. October 18, 2023 Marlett JE, Vacovsky BA, Krug EA, et al. Elopement: evidence?based mitigation and management. Worldviews Evid Based Nurs. 2024;20(6):634-641. doi:10.1111/wvn.12683. https://psnet.ahrq.gov/issue/elopement-evidence-based-mitigation-and-management …
  12. psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
    September 01, 2014 - A Costly Colonoscopy Leads to a Delay in Diagnosis Citation Text: Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35732/psn-pdf
    April 06, 2016 - The London Declaration. April 6, 2016 World Alliance for Patient Safety; World Health Organization; Patients for Patient Safety https://psnet.ahrq.gov/issue/london-declaration In this statement, Patients for Patient Safety pledge their commitment to representing and collaborating with patients to reduce medical er…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72688/psn-pdf
    October 06, 2022 - Request for proposals for clinical quality measures to improve diagnosis. October 6, 2022 Palo Alto CA; Gordon and Betty Moore Foundation: February 22, 2022.  https://psnet.ahrq.gov/issue/request-proposals-clinical-quality-measures-improve-diagnosis A lack of consensus on measures for the effectiveness and ac…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867046/psn-pdf
    October 30, 2024 - The future of safety and quality in radiation oncology. October 30, 2024 Talcott W, Covington E, Bazan J, et al. The future of safety and quality in radiation oncology. Semin Radiat Oncol. 2024;34(4):433-440. doi:10.1016/j.semradonc.2024.07.008. https://psnet.ahrq.gov/issue/future-safety-and-quality-radiation-oncol…
  16. psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
    April 30, 2014 - SPOTLIGHT CASE Diagnosing Diagnostic Mistakes Citation Text: McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google S…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49786/psn-pdf
    March 01, 2017 - Consequences of Medical Overuse March 1, 2017 Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/consequences-medical-overuse Case Objectives Define overuse and overdiagnosis. State how much of all care is estimated to be overuse. Describe why the likelihood…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34612/psn-pdf
    January 21, 2015 - Canadian Patient Safety Dictionary. January 21, 2015 Royal College of Physicians and Surgeons of Canada https://psnet.ahrq.gov/issue/canadian-patient-safety-dictionary Developed by the Systems Issues Working Group of the National Steering Committee on Patient Safety, the dictionary represents an effort to establis…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846163/psn-pdf
    March 15, 2023 - Using A.I. to detect breast cancer that doctors miss. March 15, 2023 Satariano A, Metz C. New York Times. March 5, 2023. https://psnet.ahrq.gov/issue/using-ai-detect-breast-cancer-doctors-miss Artificial intelligence (AI) is an innovation that represents great promise for diagnostic accuracy and timeliness im…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47788/psn-pdf
    March 06, 2019 - Medical device-related pressure ulcers: a systematic review and meta-analysis. March 6, 2019 Jackson D, Sarki AM, Betteridge R, et al. Medical device-related pressure ulcers: A systematic review and meta-analysis. Int J Nurs Stud. 2019;92:109-120. doi:10.1016/j.ijnurstu.2019.02.006. https://psnet.ahrq.gov/issue/me…

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