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psnet.ahrq.gov/node/47317/psn-pdf
August 15, 2018 - Actions Needed to Address Employee Misconduct
Process and Ensure Accountability.
August 15, 2018
Washington, DC: United States Government Accountability Office; July 2018. Publication GAO-18-137.
https://psnet.ahrq.gov/issue/actions-needed-address-employee-misconduct-process-and-ensure-
accountability
Both organi…
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psnet.ahrq.gov/node/45021/psn-pdf
April 06, 2016 - Scandal as a sentinel event—recognizing hidden
cost–quality trade-offs.
April 6, 2016
Bloche G. Scandal as a Sentinel Event--Recognizing Hidden Cost-Quality Trade-offs. N Engl J Med.
2016;374(11):1001-3. doi:10.1056/NEJMp1502629.
https://psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-t…
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psnet.ahrq.gov/node/45928/psn-pdf
April 24, 2018 - Comparing VA and Non-VA quality of care: a systematic
review.
April 24, 2018
O'Hanlon C, Huang C, Sloss E, et al. Comparing VA and Non-VA Quality of Care: A Systematic Review. J
Gen Intern Med. 2017;32(1):105-121. doi:10.1007/s11606-016-3775-2.
https://psnet.ahrq.gov/issue/comparing-va-and-non-va-quality-care-syst…
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psnet.ahrq.gov/node/46257/psn-pdf
October 11, 2017 - Outcomes of concurrent operations: results from the
American College of Surgeons' National Surgical Quality
Improvement Program.
October 11, 2017
Liu JB, Berian JR, Ban KA, et al. Outcomes of Concurrent Operations: Results From the American College
of Surgeons' National Surgical Quality Improvement Program. Ann Su…
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psnet.ahrq.gov/node/34769/psn-pdf
March 28, 2005 - The Challenger Launch Decision: Risky Technology,
Culture, and Deviance at NASA.
March 28, 2005
Vaughan D. Chicago, IL: University of Chicago Press; 1996. ISBN 9780226851754.
https://psnet.ahrq.gov/issue/challenger-launch-decision-risky-technology-culture-and-deviance-nasa
A model of root cause analysis on a syste…
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psnet.ahrq.gov/node/44974/psn-pdf
April 12, 2019 - Medicare letters to curb overprescribing of controlled
substances had no detectable effect on providers.
April 12, 2019
Sacarny A, Yokum D, Finkelstein A, et al. Medicare Letters To Curb Overprescribing Of Controlled
Substances Had No Detectable Effect On Providers. Health Aff (Millwood). 2016;35(3):471-9.
doi:10.…
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - Continuity Errors in Resident Clinic
Citation Text:
Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote …
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psnet.ahrq.gov/node/36812/psn-pdf
June 30, 2011 - Work patterns and fatigue-related risk among junior
doctors.
June 30, 2011
Gander P, Purnell H, Garden A, et al. Work patterns and fatigue-related risk among junior doctors. Occup
Environ Med. 2007;64(11):733-8.
https://psnet.ahrq.gov/issue/work-patterns-and-fatigue-related-risk-among-junior-doctors
Mandated work…
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psnet.ahrq.gov/node/37346/psn-pdf
March 28, 2012 - Medication administration discrepancies persist despite
electronic ordering.
March 28, 2012
FitzHenry F, Peterson JF, Arrieta M, et al. Medication Administration Discrepancies Persist Despite
Electronic Ordering. J Am Med Inform Assoc. 2007;14(6):756-764. doi:10.1197/jamia.m2359.
https://psnet.ahrq.gov/issue/medic…
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psnet.ahrq.gov/node/45415/psn-pdf
June 25, 2018 - Association of overlapping surgery with patient outcomes
in a large series of neurosurgical cases.
June 25, 2018
Howard BM, Holland CM, Mehta C, et al. Association of Overlapping Surgery With Patient Outcomes in a
Large Series of Neurosurgical Cases. JAMA Surg. 2018;153(4):313-321. doi:10.1001/jamasurg.2017.4502.
…
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psnet.ahrq.gov/node/45148/psn-pdf
April 24, 2018 - Safety of overlapping surgery at a high-volume referral
center.
April 24, 2018
Hyder JA, Hanson KT, Storlie CB, et al. Safety of Overlapping Surgery at a High-volume Referral Center.
Ann Surg. 2017;265(4):639-644. doi:10.1097/SLA.0000000000002084.
https://psnet.ahrq.gov/issue/safety-overlapping-surgery-high-volume…
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psnet.ahrq.gov/node/46819/psn-pdf
January 27, 2019 - Implementing electronic health record default settings to
reduce opioid overprescribing: a pilot study.
January 27, 2019
Zivin K, White JO, Chao S, et al. Implementing Electronic Health Record Default Settings to Reduce Opioid
Overprescribing: A Pilot Study. Pain Med. 2019;20(1):103-112. doi:10.1093/pm/pnx304.
htt…
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psnet.ahrq.gov/web-mm/returning-home-safely
December 22, 2018 - Returning Home Safely
Citation Text:
Toles M. Returning Home Safely. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/primer/electronic-health-records
March 15, 2025 - Electronic Health Records
Citation Text:
Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/60167/psn-pdf
April 12, 2024 - Discharge Planning and Transitions of Care
March 25, 2020
Bajorek SA, McElroy V. Discharge Planning and Transitions of Care. PSNet [internet]. 2020.
https://psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
Background
Transitions of care refer to the movement of patients between different healthcare se…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
October 01, 2010 - and end-stage renal disease (ESRD) on hemodialysis arrived at his outpatient dialysis center for his scheduled
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psnet.ahrq.gov/node/49541/psn-pdf
August 21, 2007 - https://psnet.ahrq.gov/web-mm/mark-my-tooth
The Case
A 45-year-old healthy man was scheduled to have
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psnet.ahrq.gov/node/49841/psn-pdf
September 01, 2018 - She
prepared the first doses of etoposide and cisplatin, which were scheduled for administration on
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psnet.ahrq.gov/node/49635/psn-pdf
September 01, 2011 - Nurse A, assigned to the patient, left the unit for her regularly scheduled break.
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psnet.ahrq.gov/node/49767/psn-pdf
August 21, 2016 - web-mm/falling-between-cracks-software
The Case
A 61-year-old man with a history of osteoarthritis was scheduled