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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/issue/making-dialysis-safer-patients-coalition
April 06, 2022 - Government Resource
Making Dialysis Safer for Patients Coalition.
Citation Text:
Making Dialysis Safer for Patients Coalition. Centers for Disease Control and Prevention.
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psnet.ahrq.gov/node/72837/psn-pdf
September 01, 2022 - Project Nurture Engages Pregnant People with Substance
Use Disorder, Improves Maternal and Infant Outcomes.
Originally published on March 11, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-
improves-maternal-and
Summary
Project…
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psnet.ahrq.gov/node/38290/psn-pdf
February 17, 2011 - Revisiting duty-hour limits — IOM recommendations for
patient safety and resident education.
February 17, 2011
Iglehart JK. Revisiting duty-hour limits--IOM recommendations for patient safety and resident education. N
Engl J Med. 2008;359(25):2633-5. doi:10.1056/NEJMp0808736.
https://psnet.ahrq.gov/issue/revisitin…
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psnet.ahrq.gov/node/45599/psn-pdf
July 02, 2017 - Inattentional blindness and failures to rescue the
deteriorating patient in critical care, emergency and
perioperative settings: four case scenarios.
July 2, 2017
Jones A, Johnstone M-J. Inattentional blindness and failures to rescue the deteriorating patient in critical
care, emergency and perioperative settings:…
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psnet.ahrq.gov/node/45791/psn-pdf
September 01, 2018 - Changes in physician practice patterns after
implementation of a communication-and-resolution
program.
September 1, 2018
Helmchen LA, Lambert BL, McDonald TB. Changes in Physician Practice Patterns after Implementation of
a Communication-and-Resolution Program. Health Serv Res. 2016;51(Suppl 3):2516-2536.
doi:10.…
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psnet.ahrq.gov/node/35511/psn-pdf
May 31, 2011 - An objective methodology for task analysis and workload
assessment in anesthesia providers.
May 31, 2011
Weinger M B, Herndon O W, Zornow M H, et al. An Objective Methodology for Task Analysis and Workload
Assessment in Anesthesia Providers. Anesthesiology. 2006;80(1):77-92. doi:10.1097/00000542-
199401000-00015.
…
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psnet.ahrq.gov/node/34957/psn-pdf
February 28, 2011 - Coordinating care across diseases, settings, and
clinicians: a key role for the generalist in practice.
February 28, 2011
Stille CJ, Jerant A, Bell D, et al. Coordinating care across diseases, settings, and clinicians: a key role for
the generalist in practice. Ann Intern Med. 2005;142(8):700-708.
https://psnet.ah…
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psnet.ahrq.gov/node/38943/psn-pdf
November 25, 2009 - Medical error reporting, patient safety, and the physician.
November 25, 2009
Anderson B, Stumpf PG, Schulkin J. Medical Error Reporting, Patient Safety, and the Physician. J Patient
Saf. 2009;5(3):176-179. doi:10.1097/pts.0b013e3181b320b0.
https://psnet.ahrq.gov/issue/medical-error-reporting-patient-safety-and-phy…
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psnet.ahrq.gov/node/35739/psn-pdf
July 15, 2010 - CT for suspected appendicitis in children: an analysis of
diagnostic errors.
July 15, 2010
Taylor GA, Callahan MJ, Rodriguez D, et al. CT for suspected appendicitis in children: an analysis of
diagnostic errors. Pediatr Radiol. 2006;36(4):331-7.
https://psnet.ahrq.gov/issue/ct-suspected-appendicitis-children-analy…
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psnet.ahrq.gov/node/47359/psn-pdf
October 10, 2018 - Is there evidence of a July effect among patients
undergoing hysterectomy surgery?
October 10, 2018
Varma S, Mehta A, Hutfless S, et al. Is there evidence of a July effect among patients undergoing
hysterectomy surgery? Am J Obstet Gynecol. 2018;219(2):176.e1-176.e9. doi:10.1016/j.ajog.2018.05.033.
https://psnet.a…
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psnet.ahrq.gov/node/46544/psn-pdf
September 12, 2018 - Interventions to improve follow-up of laboratory test
results pending at discharge: a systematic review.
September 12, 2018
Whitehead NS, Williams L, Meleth S, et al. Interventions to Improve Follow-Up of Laboratory Test Results
Pending at Discharge: A Systematic Review. J Hosp Med. 2018. doi:10.12788/jhm.2944.
ht…
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psnet.ahrq.gov/node/35218/psn-pdf
August 07, 2018 - Building a Memory: Preventing Harm, Reducing Risks and
Improving Patient Safety.
August 7, 2018
Scobie S, Thomson R. London, UK : National Patient Safety Agency; 2005.
https://psnet.ahrq.gov/issue/building-memory-preventing-harm-reducing-risks-and-improving-patient-safety
Created in 2001 to institute changes in he…
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psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
September 29, 2011 - Patient Safety and Adherence to Self-Administered Medications
Citation Text:
Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011…
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psnet.ahrq.gov/node/60552/psn-pdf
June 03, 2020 - Personal protective equipment for preventing highly
infectious diseases due to exposure to contaminated
body fluids in healthcare staff.
June 3, 2020
Verbeek JH, Rajamaki B, Ijaz S, et al. Personal protective equipment for preventing highly infectious
diseases due to exposure to contaminated body fluids in healthc…
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psnet.ahrq.gov/node/46060/psn-pdf
October 31, 2017 - Do hospitals support second victims? Collective insights
from patient safety leaders in Maryland.
October 31, 2017
Edrees HH, Morlock L, Wu AW. Do Hospitals Support Second Victims? Collective Insights From Patient
Safety Leaders in Maryland. Jt Comm J Qual Saf. 2017;43(9):471-483. doi:10.1016/j.jcjq.2017.01.008.
h…