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psnet.ahrq.gov/node/34706/psn-pdf
December 23, 2012 - Analysing potential harm in Australian general practice:
an incident-monitoring study.
December 23, 2012
Bhasale AL, Miller GC, Reid SE, et al. Analysing potential harm in Australian general practice: an incident-
monitoring study. Med J Aust. 1998;169(2):73-6.
https://psnet.ahrq.gov/issue/analysing-potential-harm…
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psnet.ahrq.gov/node/44675/psn-pdf
July 05, 2016 - Why July matters.
July 5, 2016
Petrilli CM, Del Valle J, Chopra V. Why July Matters. Acad Med. 2016;91(7):910-912.
doi:10.1097/ACM.0000000000001196.
https://psnet.ahrq.gov/issue/why-july-matters
Studies have reached conflicting conclusions about whether the "July Effect"—the belief that inpatient
mortality increa…
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psnet.ahrq.gov/node/43385/psn-pdf
August 06, 2014 - Medicines management support to older people:
understanding the context of systems failure.
August 6, 2014
Rogers S, Martin G, Rai G. Medicines management support to older people: understanding the context of
systems failure. BMJ Open. 2014;4(7):e005302. doi:10.1136/bmjopen-2014-005302.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/36964/psn-pdf
March 24, 2011 - Patients use an internet technology to report when things
go wrong.
March 24, 2011
Wasson JH, MacKenzie TA, Hall M. Patients use an internet technology to report when things go wrong.
Qual Saf Health Care. 2007;16(3):213-5.
https://psnet.ahrq.gov/issue/patients-use-internet-technology-report-when-things-go-wrong
…
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psnet.ahrq.gov/node/34692/psn-pdf
February 10, 2011 - The economic consequences of medical injuries:
implications for a no-fault insurance plan.
February 10, 2011
Johnson WG, Brennan TA, Newhouse JP, et al. The economic consequences of medical injuries.
Implications for a no-fault insurance plan. JAMA. 1992;267(18):2487-92.
https://psnet.ahrq.gov/issue/economic-conse…
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psnet.ahrq.gov/node/44572/psn-pdf
January 22, 2016 - Can social media be used as a hospital quality
improvement tool?
January 22, 2016
Lagu T, Goff SL, Craft B, et al. Can social media be used as a hospital quality improvement tool? J Hosp
Med. 2016;11(1):52-5. doi:10.1002/jhm.2486.
https://psnet.ahrq.gov/issue/can-social-media-be-used-hospital-quality-improvement-t…
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psnet.ahrq.gov/node/837791/psn-pdf
August 05, 2022 - yield false negatives for a variety
of reasons, such as testing too soon after exposure or inadequate sampling
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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
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psnet.ahrq.gov/node/47331/psn-pdf
October 17, 2018 - Description and factors associated with missed nursing
care in an acute care community hospital.
October 17, 2018
Duffy JR, Culp S, Padrutt T. Description and factors associated with missed nursing care in an acute care
community hospital. J Nurs Adm. 2018;48(7-8):361-367. doi:10.1097/NNA.0000000000000630.
https:/…
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psnet.ahrq.gov/node/35456/psn-pdf
February 19, 2010 - The working hours of hospital staff nurses and patient
safety.
February 19, 2010
Rogers AE, Hwang W-T, Scott LD, et al. The working hours of hospital staff nurses and patient safety.
Health Aff (Millwood). 2004;23(4):202-212.
https://psnet.ahrq.gov/issue/working-hours-hospital-staff-nurses-and-patient-safety
This…
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psnet.ahrq.gov/node/45996/psn-pdf
May 10, 2017 - Evaluation of medication-related clinical decision support
alert overrides in the intensive care unit.
May 10, 2017
Wong A, Amato MG, Seger DL, et al. Evaluation of medication-related clinical decision support alert
overrides in the intensive care unit. J Crit Care. 2017;39:156-161. doi:10.1016/j.jcrc.2017.02.027.
…
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psnet.ahrq.gov/node/37294/psn-pdf
May 21, 2013 - Improving Hand-Off Communication.
May 21, 2013
Oakbrook Terrace lL: Joint Commission Resources; 2007. ISBN 9781599400907.
https://psnet.ahrq.gov/issue/improving-hand-communication
The process of transferring primary responsibility for patient care is commonly referred to as a handoff.
Handoffs are inherently dange…
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psnet.ahrq.gov/node/47359/psn-pdf
October 10, 2018 - Is there evidence of a July effect among patients
undergoing hysterectomy surgery?
October 10, 2018
Varma S, Mehta A, Hutfless S, et al. Is there evidence of a July effect among patients undergoing
hysterectomy surgery? Am J Obstet Gynecol. 2018;219(2):176.e1-176.e9. doi:10.1016/j.ajog.2018.05.033.
https://psnet.a…
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psnet.ahrq.gov/node/45695/psn-pdf
December 14, 2016 - Significant reduction in preanalytical errors for
nonphlebotomy blood draws after implementation of a
novel integrated specimen collection module.
December 14, 2016
Le RD, Melanson SEF, Petrides AK, et al. Significant Reduction in Preanalytical Errors for Nonphlebotomy
Blood Draws After Implementation of a Novel I…
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psnet.ahrq.gov/node/47379/psn-pdf
November 14, 2018 - Analysis of medication therapy discontinuation orders in
new electronic prescriptions and opportunities for
implementing CancelRx.
November 14, 2018
Yang Y, Ward-Charlerie S, Kashyap N, et al. Analysis of medication therapy discontinuation orders in new
electronic prescriptions and opportunities for implementing C…
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psnet.ahrq.gov/node/34651/psn-pdf
March 04, 2011 - Incidence and types of preventable adverse events in
elderly patients: population based review of medical
records.
March 4, 2011
Thomas EJ, Brennan TA. Incidence and types of preventable adverse events in elderly patients: population
based review of medical records. BMJ. 2000;320(7237):741-4.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/47248/psn-pdf
September 26, 2018 - Frequency and nature of potentially harmful preventable
problems in primary care from the patient's perspective
with clinician review: a population-level survey in Great
Britain.
September 26, 2018
Stocks SJ, Donnelly A, Esmail A, et al. Frequency and nature of potentially harmful preventable problems
in primary …
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psnet.ahrq.gov/node/34952/psn-pdf
November 17, 2011 - Assessing the National Electronic Injury Surveillance
System—Cooperative Adverse Drug Event Surveillance
Project—six sites, United States, January 1–June 15,
2004.
November 17, 2011
Prevention C for DC and. Assessing the National Electronic Injury Surveillance System-Cooperative
Adverse Drug Event Surveillance pr…
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psnet.ahrq.gov/node/43710/psn-pdf
October 06, 2016 - Improving medication administration safety: using naïve
observation to assess practice and guide improvements
in process and outcomes.
October 6, 2016
Donaldson N, Aydin C, Fridman M, et al. Improving medication administration safety: using naïve
observation to assess practice and guide improvements in process and…
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psnet.ahrq.gov/node/46656/psn-pdf
February 07, 2018 - Autopsy interrogation of emergency medicine dispute
cases: how often are clinical diagnoses incorrect?
February 7, 2018
Liu D, Gan R, Zhang W, et al. Autopsy interrogation of emergency medicine dispute cases: how often are
clinical diagnoses incorrect? J Clin Pathol. 2018;71(1):67-71. doi:10.1136/jclinpath-2017-204…