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psnet.ahrq.gov/issue/impact-commercial-order-entry-system-prescribing-errors-amenable-computerised-decision
December 21, 2022 - Study
Impact of a commercial order entry system on prescribing errors amenable to computerised decision support in the hospital setting: a prospective pre–post study.
Citation Text:
Pontefract SK, Hodson J, Slee A, et al. Impact of a commercial order entry system on prescribing errors am…
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psnet.ahrq.gov/issue/good-care-slow-enough-be-able-pay-attention-primary-care-time-scarcity-and-patient-safety
August 04, 2015 - Study
"Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety.
Citation Text:
Satterwhite S, Nguyen M-LT, Honcharov V, et al. "Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety. J Gen Intern …
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psnet.ahrq.gov/issue/sustained-user-engagement-health-information-technology-long-road-implementation-system
December 21, 2022 - Study
Sustained user engagement in health information technology: the long road from implementation to system optimization of computerized physician order entry and clinical decision support systems for prescribing in hospitals in England.
Citation Text:
Cresswell K, Lee L, Mozaffar H, e…
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psnet.ahrq.gov/node/44434/psn-pdf
June 21, 2016 - Hospital board and management practices are strongly
related to hospital performance on clinical quality
metrics.
June 21, 2016
Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to
hospital performance on clinical quality metrics. Health Aff (Millwood). 2015;34(8):130…
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psnet.ahrq.gov/node/42354/psn-pdf
January 01, 2014 - Understanding differences in electronic health record
(EHR) use: linking individual physicians' perceptions of
uncertainty and EHR use patterns in ambulatory care.
December 18, 2013
Lanham HJ, Sittig DF, Leykum LK, et al. Understanding differences in electronic health record (EHR) use:
linking individual physician…
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psnet.ahrq.gov/node/40711/psn-pdf
August 24, 2011 - Clinical and safety impact of an inpatient pharmacist-
directed anticoagulation service.
August 24, 2011
Schillig J, Kaatz S, Hudson M, et al. Clinical and safety impact of an inpatient pharmacist-directed
anticoagulation service. J Hosp Med. 2011;6(6):322-8. doi:10.1002/jhm.910.
https://psnet.ahrq.gov/issue/clini…
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psnet.ahrq.gov/node/44026/psn-pdf
November 03, 2015 - Effect of a postdischarge virtual ward on readmission or
death for high-risk patients: a randomized clinical trial.
November 3, 2015
Dhalla IA, O'Brien T, Morra D, et al. Effect of a postdischarge virtual ward on readmission or death for high-
risk patients: a randomized clinical trial. JAMA. 2014;312(13):1305-12. …
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - SPOTLIGHT CASE
Signout Fallout
Citation Text:
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote…
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psnet.ahrq.gov/node/33580/psn-pdf
April 01, 2022 - Nursing and Patient Safety
April 21, 2021
Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/nursing-and-patient-safety
Updated in March 2021. Originally published in December 2011 by researchers at the University of
California, San Francisco. …
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psnet.ahrq.gov/node/837660/psn-pdf
July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse
Outcomes
July 8, 2022
Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
The Cases
Case 1: A 64-year-old man came in for a routine bron…
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psnet.ahrq.gov/node/865412/psn-pdf
March 27, 2024 - Delayed Diagnosis and Treatment of Systemic Lupus
Erythematosus with a Psychiatric Presentation
March 27, 2024
Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a
Psychiatric Presentation. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatmen…
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - SPOTLIGHT CASE
The Safety and Quality of Long Term Care
Citation Text:
Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Goog…
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psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - Debriefing for Clinical Learning
November 18, 2021
Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/debriefing-clinical-learning
Updated in September 2021. Originally published in December 2011 by researchers at the University of
California, S…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
February 01, 2012 - Spotlight Case July 2008
Spotlight Case
E-prescribing: E for Error?
1
2
Source and Credits
This presentation is based on the February 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical Professor, Departm…
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psnet.ahrq.gov/node/49469/psn-pdf
December 01, 2004 - Overriding Considerations
December 1, 2004
Holtzman NA. Overriding Considerations. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/overriding-considerations
The Case
Mrs. G visited her obstetrician for first trimester routine prenatal care. The obstetrician offered genetic
testing for a variety of condition…
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psnet.ahrq.gov/node/33601/psn-pdf
December 15, 2024 - Electronic Health Records
December 15, 2024
Electronic Health Records. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/electronic-health-records
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safet…
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psnet.ahrq.gov/issue/who-collaborating-centres-patient-safety
April 06, 2016 - Multi-use Website
Global Patient Safety Collaborative.
Citation Text:
Global Patient Safety Collaborative. World Alliance for Patient Safety; World Health Organization
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psnet.ahrq.gov/issue/toolkit-improving-surgical-care-and-recovery
September 18, 2024 - Toolkit
Toolkit for Improving Surgical Care and Recovery.
Citation Text:
Agency for Healthcare Research and Quality. Toolkit for Improving Surgical Care and Recovery. June 2023.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
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psnet.ahrq.gov/issue/antidote-medical-errors
May 02, 2017 - Newspaper/Magazine Article
The antidote to medical errors.
Citation Text:
The antidote to medical errors. Price M.
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…
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psnet.ahrq.gov/submit-innovations-landing
February 26, 2025 - Breadcrumb
Home
Improvement Resources
Innovations
Innovation Submissions
Individuals or organizations are encouraged to submit new or reimagined patient safety innovations that have been implemented, evaluated, sustained, and demonstrate significant improvement to patient safet…