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psnet.ahrq.gov/node/35736/psn-pdf
May 27, 2011 - Video capture of clinical care to enhance patient safety.
May 27, 2011
Weinger MB, Gonzales DC, Slagle J, et al. Video capture of clinical care to enhance patient safety. Qual
Saf Health Care. 2004;13(2):136-44.
https://psnet.ahrq.gov/issue/video-capture-clinical-care-enhance-patient-safety
This study describes th…
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psnet.ahrq.gov/node/45934/psn-pdf
March 01, 2017 - The evolving role of medical scribe: variation and
implications for organizational effectiveness and safety.
March 1, 2017
Woodcock D, Pranaat R, McGrath K, et al. The Evolving Role of Medical Scribe: Variation and Implications
for Organizational Effectiveness and Safety. Stud Health Technol Inform. 2017;234:382-38…
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psnet.ahrq.gov/node/45716/psn-pdf
September 29, 2017 - Microanalysis of video from the operating room: an
underused approach to patient safety research.
September 29, 2017
Bezemer J, Cope A, Korkiakangas T, et al. Microanalysis of video from the operating room: an underused
approach to patient safety research. BMJ Qual Saf. 2017;26(7):583-587. doi:10.1136/bmjqs-2016-00…
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psnet.ahrq.gov/node/865532/psn-pdf
April 10, 2024 - Let us to the TWISST; Plan, Simulate, Study and Act.
April 10, 2024
Colman N, Hebbar KB. Let us to the TWISST; Plan, Simulate, Study and Act. Pediatr Qual Saf.
2023;8(4):e664. doi:10.1097/pq9.0000000000000664.
https://psnet.ahrq.gov/innovation/let-us-twisst-plan-simulate-study-and-act
In situ simulation can identi…
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psnet.ahrq.gov/node/45276/psn-pdf
September 29, 2017 - Clinicians' expectations of the benefits and harms of
treatments, screening, and tests: a systematic review.
September 29, 2017
Hoffmann TC, Del Mar C. Clinicians' Expectations of the Benefits and Harms of Treatments, Screening,
and Tests: A Systematic Review. JAMA Intern Med. 2017;177(3):407-419.
doi:10.1001/jama…
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psnet.ahrq.gov/node/43907/psn-pdf
April 27, 2015 - Association of hospital participation in a surgical
outcomes monitoring program with inpatient
complications and mortality.
April 27, 2015
Etzioni DA, Wasif N, Dueck AC, et al. Association of hospital participation in a surgical outcomes
monitoring program with inpatient complications and mortality. JAMA. 2015;313…
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psnet.ahrq.gov/node/38716/psn-pdf
February 17, 2011 - Ending extra payment for "never events"—stronger
incentives for patients' safety.
February 17, 2011
Milstein A. Ending extra payment for "never events"--stronger incentives for patients' safety. N Engl J Med.
2009;360(23):2388-90. doi:10.1056/NEJMp0809125.
https://psnet.ahrq.gov/issue/ending-extra-payment-never-ev…
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psnet.ahrq.gov/node/45857/psn-pdf
July 11, 2017 - Assessing the impact of the anesthesia medication
template on medication errors during anesthesia: a
prospective study.
July 11, 2017
Grigg EB, Martin LD, Ross FJ, et al. Assessing the Impact of the Anesthesia Medication Template on
Medication Errors During Anesthesia: A Prospective Study. Anesth Analg. 2017;124(5…
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psnet.ahrq.gov/node/45878/psn-pdf
September 20, 2017 - Development of a trigger tool to identify adverse events
and harm in emergency medical services.
September 20, 2017
Howard IL, Bowen JM, Shaikh LAHA, et al. Development of a trigger tool to identify adverse events and
harm in Emergency Medical Services. Emerg Med J. 2017;34(6):391-397. doi:10.1136/emermed-2016-
20…
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psnet.ahrq.gov/node/35060/psn-pdf
November 04, 2015 - Risk factors for adverse drug events: a 10-year analysis.
November 4, 2015
Evans S, Lloyd JF, Stoddard GJ, et al. Risk factors for adverse drug events: a 10-year analysis. Ann
Pharmacother. 2005;39(7-8):1161-8.
https://psnet.ahrq.gov/issue/risk-factors-adverse-drug-events-10-year-analysis
Many medications remain a…
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psnet.ahrq.gov/node/34813/psn-pdf
July 10, 2008 - Hospital admissions due to adverse drug reactions: a
report from the Boston Collaborative Drug Surveillance
Program.
July 10, 2008
Miller RR. Hospital admissions due to adverse drug reactions. A report from the Boston Collaborative Drug
Surveillance Program. Arch Intern Med. 1974;134(2):219-23.
https://psnet.ahrq…
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psnet.ahrq.gov/node/35909/psn-pdf
October 07, 2008 - Committed to Safety: Ten Case Studies on Reducing
Harm to Patients.
October 7, 2008
McCarthy D, Blumenthal D. New York, NY: Commonwealth Fund; 2006.
https://psnet.ahrq.gov/issue/committed-safety-ten-case-studies-reducing-harm-patients
This report presents ten case studies to illustrate interventions that address p…
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psnet.ahrq.gov/node/36795/psn-pdf
August 26, 2011 - Surgical specimen identification errors: a new measure of
quality in surgical care.
August 26, 2011
Makary MA, Epstein J, Pronovost P, et al. Surgical specimen identification errors: a new measure of quality
in surgical care. Surgery. 2007;141(4):450-5.
https://psnet.ahrq.gov/issue/surgical-specimen-identification…
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psnet.ahrq.gov/node/34693/psn-pdf
February 10, 2011 - Effect of outcome on physician judgments of
appropriateness of care.
February 10, 2011
Caplan RA, Posner KL, Cheney FW. Effect of outcome on physician judgments of appropriateness of care.
JAMA. 1991;265(15):1957-60.
https://psnet.ahrq.gov/issue/effect-outcome-physician-judgments-appropriateness-care
The authors …
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psnet.ahrq.gov/node/46319/psn-pdf
August 09, 2017 - Opioids in Medicare Part D: Concerns About Extreme Use
and Questionable Prescribing.
August 9, 2017
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; July
2017. Report No. OEI-02-17-00250.
https://psnet.ahrq.gov/issue/opioids-medicare-part-d-concerns-about-extreme-use-and…
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psnet.ahrq.gov/node/34013/psn-pdf
December 22, 2008 - Defining and measuring patient safety.
December 22, 2008
Pronovost P, Thompson DA, Holzmueller CG, et al. Defining and measuring patient safety. Crit Care Clin.
2005;21(1):1-19, vii.
https://psnet.ahrq.gov/issue/defining-and-measuring-patient-safety
This review discusses the increasing demand for improving patient…
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psnet.ahrq.gov/node/60814/psn-pdf
August 19, 2020 - Missed acute myocardial infarction in the emergency
department-standardizing measurement of misdiagnosis-
related harms using the SPADE method.
August 19, 2020
Sharp AL, Baecker A, Nassery N, et al. Missed acute myocardial infarction in the emergency
department–standardizing measurement of misdiagnosis-related har…
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psnet.ahrq.gov/node/47876/psn-pdf
March 27, 2019 - Evaluation of medication errors at the transition of care
from an ICU to non-ICU location.
March 27, 2019
Tully AP, Hammond DA, Li C, et al. Evaluation of Medication Errors at the Transition of Care From an ICU
to Non-ICU Location. Crit Care Med. 2019;47(4):543-549. doi:10.1097/CCM.0000000000003633.
https://psnet.…
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psnet.ahrq.gov/node/764396/psn-pdf
March 02, 2022 - Family Input for Quality and Safety (FIQS): using mobile
technology for in-hospital reporting from families and
patients.
March 2, 2022
Bardach NS, Stotts JR, Fiore DM, et al. Family Input for Quality and Safety (FIQS): Using mobile
technology for in?hospital reporting from families and patients. J Hosp Med. 2022;…
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psnet.ahrq.gov/node/73130/psn-pdf
January 01, 2022 - Improving peripherally inserted central catheter
appropriateness and reducing device-related
complications: a quasiexperimental study in 52 Michigan
hospitals.
April 14, 2021
Chopra V, O'Malley M, Horowitz J, et al. Improving peripherally inserted central catheter appropriateness
and reducing device-related compl…