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psnet.ahrq.gov/issue/path-safety-benefits-2005-patient-safety-and-quality-improvement-act
June 03, 2015 - Commentary
Path to safety: benefits of the 2005 Patient Safety and Quality Improvement Act.
Citation Text:
McBride D, Greening A, Redmond D. Path to safety: benefits of the 2005 Patient Safety and Quality Improvement Act. Healthc Financ Manage. 2006;60(6):84-8.
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psnet.ahrq.gov/issue/using-ismp-medication-safety-self-assessment-improve-medication-use-processes
January 05, 2017 - Study
Using the ISMP Medication Safety Self-Assessment to improve medication use processes.
Citation Text:
Lesar TS, Mattis A, Anderson E, et al. Using the ISMP Medication Safety Self-Assessment to improve medication use processes. Jt Comm J Qual Saf. 2003;29(5):211-26.
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psnet.ahrq.gov/issue/national-incidence-medication-error-surgical-patients-and-after-accreditation-council
September 23, 2020 - Study
National incidence of medication error in surgical patients before and after Accreditation Council for Graduate Medical Education duty-hour reform.
Citation Text:
Vadera S, Griffith SD, Rosenbaum BP, et al. National Incidence of Medication Error in Surgical Patients Before and Afte…
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psnet.ahrq.gov/web-mm/hemolysis-holdup
July 03, 2016 - Hemolysis Holdup
Citation Text:
Lehman CM. Hemolysis Holdup. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/node/34010/psn-pdf
June 20, 2019 - ISMP Medication Safety Alert!® Nurse-Advise ERR.
June 20, 2019
Plymouth Meeting, PA: Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/ismp-medication-safety-alertr-nurse-advise-err
ISMP's newsletter was designed to specifically meet the needs of nurses who transcribe medication orders,
adminis…
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psnet.ahrq.gov/issue/negligent-care-and-malpractice-claiming-behavior-utah-and-colorado
June 23, 2015 - Study
Classic
Negligent care and malpractice claiming behavior in Utah and Colorado.
Citation Text:
Studdert DM, Thomas EJ, Burstin HR, et al. Negligent care and malpractice claiming behavior in Utah and Colorado. Med Care. 2000;38(3):250-60.
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psnet.ahrq.gov/node/866567/psn-pdf
August 21, 2024 - A daily dose of communication to improve quality and
safety outcomes.
August 21, 2024
Halm MA. A daily dose of communication to improve quality and safety outcomes. Am J Crit Care.
2024;33(4):305-310. doi:10.4037/ajcc2024318.
https://psnet.ahrq.gov/issue/daily-dose-communication-improve-quality-and-safety-outcomes…
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psnet.ahrq.gov/node/73202/psn-pdf
April 28, 2021 - however, may be lower in community
practice than in the manufacturer’s testing due to viral dynamics, sampling
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psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - may be lower in community practice than in the manufacturer’s testing due to viral dynamics, sampling
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psnet.ahrq.gov/node/43646/psn-pdf
January 01, 2021 - Patient Safety Systems Chapter.
January 1, 2021
In: 2021 Comprehensive Accreditation Manual for Hospitals. CAMH. Oakbrook Terrace, IL: Joint
Commission; January 2021:PS1-PS46.
https://psnet.ahrq.gov/issue/patient-safety-systems-chapter
This chapter provides information about how organizations can re-design existin…
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psnet.ahrq.gov/node/851646/psn-pdf
January 01, 2024 - Burden of serious harms from diagnostic error in the
USA.
July 28, 2023
Newman-Toker DE, Nassery N, Schaffer AC, et al. Burden of serious harms from diagnostic error in the
USA. BMJ Qual Saf. 2024;33(2):109-120. doi:10.1136/bmjqs-2021-014130.
https://psnet.ahrq.gov/issue/burden-serious-harms-diagnostic-error-usa
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psnet.ahrq.gov/web-mm/unfamiliar-catheter
November 01, 2006 - Each lumen of a multi-lumen catheter is used for a different purpose, such as sampling, total parenteral
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psnet.ahrq.gov/node/866814/psn-pdf
September 25, 2024 - Accuracy of a proprietary large language model in
labeling obstetric incident reports.
September 25, 2024
Johnson J, Brown C, Lee GM, et al. Accuracy of a proprietary large language model in labeling obstetric
incident reports. Jt Comm J Qual Patient Saf. 2024;50(12):877-881. doi:10.1016/j.jcjq.2024.08.001.
https:…
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psnet.ahrq.gov/node/866955/psn-pdf
October 16, 2024 - Adverse diagnostic events in hospitalised patients: a
single-centre, retrospective cohort study.
October 16, 2024
Dalal AK, Plombon S, Konieczny K, et al. Adverse diagnostic events in hospitalised patients: a single-
centre, retrospective cohort study. BMJ Qual Saf. 2024;Epub Oct 1. doi:10.1136/bmjqs-2024-017183.
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psnet.ahrq.gov/issue/incidence-never-events-among-weekend-admissions-versus-weekday-admissions-us-hospitals
November 03, 2015 - Study
Classic
Incidence of "never events" among weekend admissions versus weekday admissions to US hospitals: national analysis.
Citation Text:
Attenello FJ, Wen T, Cen SY, et al. Incidence of "never events" among weekend admissions versus weekday admissions to …
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psnet.ahrq.gov/node/74213/psn-pdf
December 22, 2021 - Burnout, engagement, and dental errors among U.S.
dentists.
December 22, 2021
Yansane A, Tokede O, Walji MF, et al. Burnout, engagement, and dental errors among U.S. dentists. J
Patient Saf. 2021;17(8):e1050-e1056. doi:10.1097/pts.0000000000000673.
https://psnet.ahrq.gov/issue/burnout-engagement-and-dental-errors-…
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psnet.ahrq.gov/node/33591/psn-pdf
March 15, 2025 - Triggers and Trigger Tools
March 15, 2025
Triggers and Trigger Tools. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/triggers-and-trigger-tools
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/node/865590/psn-pdf
April 17, 2024 - An electronic trigger to detect telemedicine-related
diagnostic errors.
April 17, 2024
Murphy DR, Kadiyala H, Wei L, et al. An electronic trigger to detect telemedicine-related diagnostic errors.
J Telemed Telecare. 2024;Epub Apr 1. doi:10.1177/1357633x241236570.
https://psnet.ahrq.gov/issue/electronic-trigger-det…
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psnet.ahrq.gov/node/851459/psn-pdf
July 19, 2023 - Racial and ethnic bias in the diagnosis of alcohol use
disorder in veterans.
July 19, 2023
Vickers-Smith R, Justice AC, Becker WC, et al. Racial and ethnic bias in the diagnosis of alcohol use
disorder in veterans. Am J Psych. 2023;180(6):426-436. doi:10.1176/appi.ajp.21111097.
https://psnet.ahrq.gov/issue/racial-…
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - bronchoscopy not only provides visualization of the lower respiratory tract but can also allow for various sampling