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psnet.ahrq.gov/node/852798/psn-pdf
August 23, 2023 - Patient handoffs and multi-specialty trainee perspectives
across an institution: informing recommendations for
health systems and an expanded conceptual framework
for handoffs.
August 23, 2023
Williams SR, Sebok-Syer SS, Caretta-Weyer H, et al. Patient handoffs and multi-specialty trainee
perspectives across an i…
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psnet.ahrq.gov/node/74162/psn-pdf
December 08, 2021 - Impact of state nurse practitioner regulations on
potentially inappropriate medication prescribing between
physicians and nurse practitioners: a national study in
the United States.
December 8, 2021
Tzeng H-M, Raji MA, Chou L-N, et al. Impact of state nurse practitioner regulations on potentially
inappropriate me…
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psnet.ahrq.gov/node/36027/psn-pdf
March 28, 2011 - Medical injuries among hospitalized children.
March 28, 2011
Meurer JR, Yang H, Guse CE, et al. Medical injuries among hospitalized children. Qual Saf Health Care.
2006;15(3):202-7.
https://psnet.ahrq.gov/issue/medical-injuries-among-hospitalized-children
This AHRQ–funded study applied new screening criteria to ca…
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psnet.ahrq.gov/node/43995/psn-pdf
August 02, 2015 - Patient access to electronic health records during
hospitalization.
August 2, 2015
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.
https://psnet.ahrq.gov/issue/patient-access-electronic…
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psnet.ahrq.gov/node/40844/psn-pdf
January 04, 2012 - Intensive care unit readmissions in U.S. hospitals: patient
characteristics, risk factors, and outcomes.
January 4, 2012
Kramer AA, Higgins TL, Zimmerman JE. Intensive care unit readmissions in U.S. hospitals: patient
characteristics, risk factors, and outcomes. Crit Care Med. 2012;40(1):3-10.
doi:10.1097/CCM.0b01…
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psnet.ahrq.gov/node/38416/psn-pdf
February 18, 2009 - Preanalytical errors in primary healthcare: a
questionnaire study of information search procedures,
test request management and test tube labelling.
February 18, 2009
Söderberg J, Brulin C, Grankvist K, et al. Preanalytical errors in primary healthcare: a questionnaire study
of information search procedures, test …
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psnet.ahrq.gov/node/49784/psn-pdf
February 01, 2017 - Safeguarding Diagnostic Testing at the Point of Care
February 1, 2017
Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care
The Case
A 23-year-old woman presented to the family medicine clinic for…
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psnet.ahrq.gov/node/33665/psn-pdf
March 01, 2008 - Creation of a Medical Procedure Service to Improve
Patient Safety
March 1, 2008
Smith CC, CHuang G. Creation of a Medical Procedure Service to Improve Patient Safety. PSNet [internet].
2008.
https://psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety
Perspective
Introduction and …
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psnet.ahrq.gov/node/43568/psn-pdf
April 25, 2016 - Medication safety in the operating room: a survey of
preparation methods and drug concentration
consistencies in children's hospitals in the United States.
April 25, 2016
Shaw RE, Litman RS. Medication Safety in the Operating Room: A Survey of Preparation Methods and
Drug Concentration Consistencies in Children's …
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psnet.ahrq.gov/node/44431/psn-pdf
October 21, 2015 - Use of a human factors classification framework to
identify causal factors for medication and medical device-
related adverse clinical incidents.
October 21, 2015
Mitchell RJ, Williamson A, Molesworth B. Use of a human factors classification framework to identify causal
factors for medication and medical device-re…
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psnet.ahrq.gov/node/47408/psn-pdf
September 19, 2018 - Ways to Improve Electronic Health Record Safety.
September 19, 2018
Philadelphia, PA: Pew Charitable Trusts, American Medical Association, and Medstar Health; 2018.
https://psnet.ahrq.gov/issue/ways-improve-electronic-health-record-safety
Electronic health records both contribute to and detract from safe care. This…
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psnet.ahrq.gov/node/34061/psn-pdf
January 04, 2017 - Patient Safety Leadership WalkRounds.
January 4, 2017
Frankel A, Graydon-Baker E, Neppl C, et al. Patient Safety Leadership WalkRounds. Jt Comm J Qual Saf.
2003;29(1). doi:10.1016/s1549-3741(03)29003-1.
https://psnet.ahrq.gov/issue/patient-safety-leadership-walkrounds
This study shares the concept of an interventi…
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psnet.ahrq.gov/node/867379/psn-pdf
January 01, 2025 - Implementation of electronic triggers to identify
diagnostic errors in emergency departments.
December 18, 2024
Vaghani V, Gupta A, Mir U, et al. Implementation of electronic triggers to identify diagnostic errors in
emergency departments. JAMA Intern Med. 2025;185(2):143-151. doi:10.1001/jamainternmed.2024.6214.
…
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psnet.ahrq.gov/node/60933/psn-pdf
September 23, 2020 - Seroprevalence of SARS-CoV-2 among frontline health
care personnel in a multistate hospital network--13
academic medical centers, April-June 2020.
September 23, 2020
Self WH, Tenforde MW, Stubblefield WB, et al. Seroprevalence of SARS-CoV-2 among frontline health
care personnel in a multistate hospital network - 1…
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psnet.ahrq.gov/node/838251/psn-pdf
October 05, 2022 - Serious hazards of transfusion: evaluating the dangers of
a wrong patient autologous salvaged blood in cardiac
surgery.
October 5, 2022
Uramatsu M, Maeda H, Mishima S, et al. Serious hazards of transfusion: evaluating the dangers of a wrong
patient autologous salvaged blood in cardiac surgery. J Cardiothorac Surg.…
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psnet.ahrq.gov/node/60278/psn-pdf
April 29, 2020 - Assessing patient safety in a pediatric telemedicine
setting: a multi-methods study.
April 29, 2020
Haimi M, Brammli-Greenberg S, Baron-Epel O, et al. Assessing patient safety in a pediatric telemedicine
setting: a multi-methods study. BMC Med Inform Decis Mak. 2020;20(1). doi:10.1186/s12911-020-1074-7.
https://ps…
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psnet.ahrq.gov/node/44936/psn-pdf
May 09, 2017 - Potential benefit of electronic pharmacy claims data to
prevent medication history errors and resultant inpatient
order errors.
May 9, 2017
Pevnick JM, Palmer KA, Shane R, et al. Potential benefit of electronic pharmacy claims data to prevent
medication history errors and resultant inpatient order errors. J Am Med…
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psnet.ahrq.gov/node/45271/psn-pdf
August 10, 2016 - Patient identification and tube labelling—a call for
harmonisation.
August 10, 2016
van Dongen-Lases EC, Cornes MP, Grankvist K, et al. Patient identification and tube labelling – a call for
harmonisation. Clinical Chemistry and Laboratory Medicine (CCLM). 2016;54(7). doi:10.1515/cclm-2015-
1089.
https://psnet.ah…
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psnet.ahrq.gov/node/44076/psn-pdf
May 19, 2018 - The trigger tool as a method to measure harmful
medication errors in children.
May 19, 2018
Maaskant JM, Smeulers M, Bosman D, et al. The Trigger Tool as a Method to Measure Harmful Medication
Errors in Children. J Patient Saf. 2018;14(2):95-100. doi:10.1097/PTS.0000000000000177.
https://psnet.ahrq.gov/issue/trigg…
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psnet.ahrq.gov/node/47181/psn-pdf
August 22, 2018 - Critical role of the surgeon–anesthesiologist relationship
for patient safety.
August 22, 2018
Cooper JB. Critical Role of the Surgeon-Anesthesiologist Relationship for Patient Safety. Anesthesiology.
2018;129(3):402-405. doi:10.1097/ALN.0000000000002324.
https://psnet.ahrq.gov/issue/critical-role-surgeon-anesthes…