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psnet.ahrq.gov/issue/patient-safety-and-adverse-events
July 20, 2022 - Special or Theme Issue
Patient Safety and Adverse Events.
Citation Text:
Patient Safety and Adverse Events. Adlassnig KP, Blobel B, Mantas J, Masic I, eds. Stud Health Technol Inform. 2009;150:497-566. In: Medical Informatics in a United and Healthy Europe. Washington, DC: IOS Press. ISB…
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psnet.ahrq.gov/issue/preventing-medication-errors-hospitals-through-systems-approach-and-technological-innovation
September 11, 2019 - Commentary
Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010.
Citation Text:
Crane J, Crane FG. Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for…
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psnet.ahrq.gov/issue/effectiveness-random-and-focused-review-detecting-surgical-pathology-error
August 04, 2021 - Study
Effectiveness of random and focused review in detecting surgical pathology error.
Citation Text:
Raab SS, Grzybicki DM, Mahood LK, et al. Effectiveness of random and focused review in detecting surgical pathology error. Am J Clin Pathol. 2008;130(6):905-12. doi:10.1309/AJCPPIA5…
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psnet.ahrq.gov/issue/first-know-thyself-cognition-and-error-medicine
March 09, 2022 - Review
"First, know thyself": cognition and error in medicine.
Citation Text:
Elia F, Aprà F, Verhovez A, et al. "First, know thyself": cognition and error in medicine. Acta Diabetol. 2016;53(2):169-175. doi:10.1007/s00592-015-0762-8.
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psnet.ahrq.gov/issue/evaluation-inpatient-admissions-and-potential-antimicrobial-and-analgesic-dosing-errors
September 23, 2020 - Study
Evaluation of inpatient admissions and potential antimicrobial and analgesic dosing errors in overweight children.
Citation Text:
Miller JL, Johnson PN, Harrison DL, et al. Evaluation of inpatient admissions and potential antimicrobial and analgesic dosing errors in overweight chi…
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psnet.ahrq.gov/issue/cms-proposal-suppress-hospital-safety-data-angers-advocates-agency-says-covid-disruptions
June 15, 2022 - Newspaper/Magazine Article
CMS proposal to suppress hospital safety data angers advocates — agency says COVID disruptions, staff shortages hamper ability to fairly score poor performers.
Citation Text:
CMS proposal to suppress hospital safety data angers advocates — agency says COVID dis…
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psnet.ahrq.gov/issue/potential-medical-adverse-events-associated-death-forensic-pathology-perspective
July 31, 2019 - Study
Potential medical adverse events associated with death: a forensic pathology perspective.
Citation Text:
Sakai K, Takatsu A, Shigeta A, et al. Potential medical adverse events associated with death: a forensic pathology perspective. International Journal for Quality in Health Car…
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psnet.ahrq.gov/issue/cleaning-discharge-process-number-components-and-personnel-are-crucial-success
October 20, 2021 - Commentary
Cleaning up the discharge process: a number of components—and personnel—are crucial to success.
Citation Text:
Huber C, Blanco M. Cleaning up the discharge process: a number of components--and personnel--are crucial to success. Am J Nurs. 2010;110(9):66-69. doi:10.1097/01.NA…
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psnet.ahrq.gov/issue/hastened-death-due-disease-burden-and-distress-has-not-received-timely-quality-palliative
October 31, 2023 - Commentary
Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error.
Citation Text:
Gallagher R, Passmore MJ, Baldwin C. Hastened death due to disease burden and distress that has not received timely, quality palliative ca…
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psnet.ahrq.gov/issue/pharmacist-and-prescriber-responsibilities-avoiding-prescription-drug-misuse
October 13, 2018 - Commentary
Pharmacist and prescriber responsibilities for avoiding prescription drug misuse.
Citation Text:
Pharmacist and prescriber responsibilities for avoiding prescription drug misuse. AMA J Ethics. 2021;23(6):E471-479. doi:10.1001/amajethics.2021.471.
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psnet.ahrq.gov/web-mm/transfer-or-not-transfer
November 23, 2016 - Stable patients may request transfer to a particular in-zone hospital (consideration is given to where … But when there is a request or indication to transfer outside the zone, EMS providers must contact a
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psnet.ahrq.gov/issue/physician-communication-when-prescribing-new-medications
December 16, 2009 - Study
Physician communication when prescribing new medications.
Citation Text:
Tarn DM, Heritage J, Paterniti DA, et al. Physician communication when prescribing new medications. Arch Intern Med. 2006;166(17):1855-1862.
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psnet.ahrq.gov/issue/medicolegal-aspect-error-pathology-search-jury-verdicts-and-settlements
February 04, 2016 - Review
The medicolegal aspect of error in pathology: a search of jury verdicts and settlements.
Citation Text:
Kornstein MJ, Byrne SP. The medicolegal aspect of error in pathology: a search of jury verdicts and settlements. Arch Pathol Lab Med. 2007;131(4):615-618.
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psnet.ahrq.gov/issue/implementing-rise-second-victim-support-programme-johns-hopkins-hospital-case-study
March 03, 2019 - Study
Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study.
Citation Text:
Edrees HH, Connors C, Paine LA, et al. Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study. BMJ Open. 2016;6(9):e011708. d…
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psnet.ahrq.gov/issue/new-electronic-health-records-unknown-queue-caused-multiple-events-patient-harm
October 12, 2022 - Book/Report
The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm.
Citation Text:
The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm. Washington, DC: VA Office of the Inspector General; July 14 2022. Report No. 22-011…
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psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
January 01, 2019 - Psychiatric consultation services routinely conduct both types of
evaluations
• Timing of patient’s request
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psnet.ahrq.gov/issue/discrepancies-between-clinical-diagnoses-and-autopsy-findings-critically-ill-children
January 12, 2022 - Study
Discrepancies between clinical diagnoses and autopsy findings in critically ill children: a prospective study.
Citation Text:
Carlotti APCP, Bachette LG, Carmona F, et al. Discrepancies Between Clinical Diagnoses and Autopsy Findings in Critically Ill Children: A Prospective Study.…
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psnet.ahrq.gov/issue/use-novel-modified-fishbone-diagram-analyze-diagnostic-errors
February 13, 2019 - Commentary
Use of a novel, modified fishbone diagram to analyze diagnostic errors.
Citation Text:
Reilly JB, Myers JS, Salvador D, et al. Use of a novel, modified fishbone diagram to analyze diagnostic errors. Diagnosis (Berl). 2014;1(2):167-171. doi:10.1515/dx-2013-0040.
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psnet.ahrq.gov/issue/patient-access-electronic-health-records-during-hospitalization
October 19, 2022 - Study
Patient access to electronic health records during hospitalization.
Citation Text:
Pell JM, Mancuso M, Limon S, et al. Patient access to electronic health records during hospitalization. JAMA Intern Med. 2015;175(5):856-858. doi:10.1001/jamainternmed.2015.121.
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psnet.ahrq.gov/issue/need-closed-loop-systems-management-abnormal-test-results
May 20, 2019 - Study
The need for closed-loop systems for management of abnormal test results.
Citation Text:
Zuccotti G, Samal L, Maloney FL, et al. The Need for Closed-Loop Systems for Management of Abnormal Test Results. Ann Intern Med. 2018;168(11):820-821. doi:10.7326/M17-2425.
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