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  1. 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…
  2. 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 …
  3. 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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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. …
  8. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…
  9. Psn-Pdf (pdf file)

    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.  …
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. 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. Copy Citation Format: Goog…
  13. Psn-Pdf (pdf file)

    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…
  14. 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…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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…
  17. 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 Copy Citation Save Save to your library Print Download PDF Share Facebook …
  18. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
  19. 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. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …
  20. 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…

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