-
psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
January 01, 2014 - Annual Perspective
Computerized Provider Order Entry and Patient Safety
Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2015
View more articles from the same authors.
Citation Text:
Sarkar U, Shojania KG. Computerized Provider Order Entry and Patien…
-
psnet.ahrq.gov/taxonomy/term/3460
August 11, 2025 - Swiss Cheese Model
Reason developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard. In the model, each slice of cheese represents a safety barrier or precaution relevant to a particular …
-
psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Although the patient’s bilirubin was mildly elevated, this is a non-specific finding
and could have represented
-
psnet.ahrq.gov/perspective/becoming-patient-safety-organization
July 01, 2011 - stakeholder communities, and begins to rationalize both substantively and electronically how things are represented
-
psnet.ahrq.gov/node/47666/psn-pdf
January 01, 2020 - A partially structured postoperative handoff protocol
improves communication in 2 mixed surgical intensive
care units: findings from the Handoffs and Transitions in
Critical Care (HATRICC) prospective cohort study.
February 6, 2019
Lane-Fall MB, Pascual JL, Peifer HG, et al. A Partially Structured Postoperative Ha…
-
psnet.ahrq.gov/node/40477/psn-pdf
March 23, 2012 - Adverse drug events in U.S. adult ambulatory medical
care.
March 23, 2012
Sarkar U, Lopez A, Maselli JH, et al. Adverse drug events in U.S. adult ambulatory medical care. Health
Serv Res. 2011;46(5):1517-1533. doi:10.1111/j.1475-6773.2011.01269.x.
https://psnet.ahrq.gov/issue/adverse-drug-events-us-adult-ambulator…
-
psnet.ahrq.gov/node/34794/psn-pdf
November 18, 2015 - Accident analysis of large-scale technological disasters
applied to an anaesthetic complication.
November 18, 2015
Eagle CJ, Davies JM, Reason J. Accident analysis of large-scale technological disasters applied to an
anaesthetic complication. Can J Anaesth. 1992;39(2):118-22.
https://psnet.ahrq.gov/issue/accident-…
-
psnet.ahrq.gov/node/35886/psn-pdf
July 23, 2010 - In-house, overnight physician staffing: a cross-sectional
survey of Canadian adult and pediatric intensive care
units.
July 23, 2010
Parshuram CS, Kirpalani H, Mehta S, et al. In-house, overnight physician staffing: a cross-sectional survey
of Canadian adult and pediatric intensive care units. Crit Care Med. 2006;…
-
psnet.ahrq.gov/node/42705/psn-pdf
November 26, 2013 - Improving America's Hospitals: The Joint Commission's
Annual Report on Quality and Safety 2013.
November 26, 2013
Oakbrook Terrace, IL: The Joint Commission; October 2013.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety-2013
This Joint Commission…
-
psnet.ahrq.gov/node/47582/psn-pdf
December 12, 2018 - Success in hospital-acquired pressure ulcer prevention: a
tale in two data sets.
December 12, 2018
Smith S, Snyder A, McMahon LF, et al. Success In Hospital-Acquired Pressure Ulcer Prevention: A Tale In
Two Data Sets. Health Aff (Millwood). 2018;37(11):1787-1796. doi:10.1377/hlthaff.2018.0712.
https://psnet.ahrq.g…
-
psnet.ahrq.gov/node/34775/psn-pdf
February 07, 2019 - Escape Fire: Lessons for the Future of Health Care.
February 7, 2019
Berwick DM. Washington DC: Commonwealth Fund; 2002.
https://psnet.ahrq.gov/issue/escape-fire-lessons-future-health-care
This report represents an edited version of Donald Berwick’s Plenary Address presented at the Institute for
Healthcare Improve…
-
psnet.ahrq.gov/node/45700/psn-pdf
September 01, 2018 - Resolving malpractice claims after tort reform: experience
in a self-insured Texas public academic health system.
September 1, 2018
Sage WM, Harding MC, Thomas EJ. Resolving Malpractice Claims after Tort Reform: Experience in a Self-
Insured Texas Public Academic Health System. Health Serv Res. 2016;51 Suppl 3:2615…
-
psnet.ahrq.gov/node/42149/psn-pdf
December 23, 2016 - Medical device alarm safety in hospitals.
December 23, 2016
Medical device alarm safety in hospitals. Sentinel event alert. 2013;(50):1-3.
https://psnet.ahrq.gov/issue/medical-device-alarm-safety-hospitals
The cacophony of alarms in hospitals has led many health care providers to become desensitized to them,
a con…
-
psnet.ahrq.gov/node/35324/psn-pdf
February 03, 2011 - Neurobehavioral performance of residents after heavy
night call vs after alcohol ingestion.
February 3, 2011
Arnedt JT, Owens J, Crouch M, et al. Neurobehavioral Performance of Residents After Heavy Night Call vs
After Alcohol Ingestion. JAMA. 2005;294(9). doi:10.1001/jama.294.9.1025.
https://psnet.ahrq.gov/issue/…
-
psnet.ahrq.gov/node/38412/psn-pdf
September 01, 2016 - Overrides of medication alerts in ambulatory care.
September 1, 2016
Isaac T, Weissman JS, Davis RB, et al. Overrides of medication alerts in ambulatory care. Arch Intern Med.
2009;169(3):305-311. doi:10.1001/archinternmed.2008.551.
https://psnet.ahrq.gov/issue/overrides-medication-alerts-ambulatory-care
The safet…
-
psnet.ahrq.gov/node/35467/psn-pdf
March 11, 2011 - The impact of electronic health records on time efficiency
of physicians and nurses: a systematic review.
March 11, 2011
Poissant L, Pereira J, Tamblyn R, et al. The impact of electronic health records on time efficiency of
physicians and nurses: a systematic review. J Am Med Inform Assoc. 2005;12(5):505-16.
https…
-
psnet.ahrq.gov/issue/hallmarks-quality-and-patient-safety-recommended-baccalaureate-competencies-and-curricular
November 27, 2023 - Newspaper/Magazine Article
Hallmarks of quality and patient safety recommended baccalaureate competencies and curricular guidelines to ensure high-quality and safe patient care.
Citation Text:
Hallmarks of quality and patient safety: recommended baccalaureate competencies and curricula…
-
psnet.ahrq.gov/web-mm/x-ray-flip
August 10, 2019 - X-ray Flip
Citation Text:
Shapiro MJ. X-ray Flip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downl…
-
psnet.ahrq.gov/node/41726/psn-pdf
September 26, 2012 - Improving America's Hospitals: The Joint Commission's
Annual Report on Quality and Safety 2012.
September 26, 2012
Oakbrook Terrace, IL: The Joint Commission; September 2012.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety-2012
The seventh annual Joint…
-
psnet.ahrq.gov/node/42692/psn-pdf
April 21, 2015 - Surgical skill and complication rates after bariatric
surgery.
April 21, 2015
Birkmeyer JD, Finks JF, O'Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl
J Med. 2013;369(15):1434-1442. doi:10.1056/NEJMsa1300625.
https://psnet.ahrq.gov/issue/surgical-skill-and-complication-rates…