-
psnet.ahrq.gov/issue/five-reasons-optimism-world-patient-safety-day
March 30, 2022 - Commentary
Five reasons for optimism on World Patient Safety Day.
Citation Text:
Fontana G, Flott K, Dhingra-Kumar N, et al. Five reasons for optimism on World Patient Safety Day. Lancet. 2019;394(10203):993-995. doi:10.1016/S0140-6736(19)32134-8.
Copy Citation
Format:
DOI …
-
psnet.ahrq.gov/issue/standard-admission-order-sets-promote-ordering-unnecessary-investigations-quasi-randomised
March 24, 2021 - Study
Standard admission order sets promote ordering of unnecessary investigations: a quasi-randomised evaluation in a simulated setting.
Citation Text:
Leis B, Frost A, Bryce R, et al. Standard admission order sets promote ordering of unnecessary investigations: a quasi-randomised evalu…
-
psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - Sepsis is a very heterogeneous disease that is difficult to diagnose in its early stages and difficult … to treat in its later stages; however, routine screening may aid in early identification.
-
psnet.ahrq.gov/node/33774/psn-pdf
December 01, 2014 - You have a lot of different countries that are probably at different stages in their
technological journey … You wonder whether we're at the early stages of a set of world flattening
forces with technology and
-
psnet.ahrq.gov/issue/empowering-frontline-nurses-structured-intervention-enables-nurses-improve-medication
March 13, 2012 - Study
Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.
Citation Text:
Kliger J, Blegen MA, Gootee D, et al. Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accur…
-
psnet.ahrq.gov/issue/adverse-drug-event-rates-six-community-hospitals-and-potential-impact-computerized-physician
January 03, 2017 - Study
Adverse drug event rates in six community hospitals and the potential impact of computerized physician order entry for prevention.
Citation Text:
Hug BL, Witkowski DJ, Sox CM, et al. Adverse Drug Event Rates in Six Community Hospitals and the Potential Impact of Computerized Phys…
-
psnet.ahrq.gov/issue/where-errors-occur-preparation-and-administration-intravenous-medicines-systematic-review-and
June 30, 2011 - Review
Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis.
Citation Text:
McDowell SE, Mt-Isa S, Ashby D, et al. Where errors occur in the preparation and administration of intravenous medicines: a systematic rev…
-
psnet.ahrq.gov/node/35007/psn-pdf
May 22, 2009 - Peripheral vision: expertise in real world contexts.
May 22, 2009
Dreyfus HL, Dreyfus SE. Peripheral Vision. Organization Studies. 2005;26(5).
doi:10.1177/0170840605053102.
https://psnet.ahrq.gov/issue/peripheral-vision-expertise-real-world-contexts
The authors describe a five-stage model of acquiring expertise an…
-
psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - Spotlight
Spotlight
Dangers of Missing an Epidural Abscess:
Multiple Visits and Delayed Diagnosis with
a Severely Negative Outcome
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Comm…
-
psnet.ahrq.gov/node/867804/psn-pdf
February 26, 2025 - While AI applications in health care are still in early stages, commentators suggest that AI
may help
-
psnet.ahrq.gov/issue/importance-safety-climate-teamwork-climate-and-demographics-understanding-nurses-allied
October 13, 2021 - Study
Importance of safety climate, teamwork climate and demographics: understanding nurses, allied health professionals and clerical staff perceptions of patient safety.
Citation Text:
Zaheer S, Ginsburg LR, Wong HJ, et al. Importance of safety climate, teamwork climate and demographics…
-
psnet.ahrq.gov/issue/practice-indicators-suboptimal-care-and-avoidable-adverse-events-content-analysis-national
May 13, 2015 - Study
Practice indicators of suboptimal care and avoidable adverse events: a content analysis of a national qualifying examination.
Citation Text:
Bordage G, Meguerditchian A-N, Tamblyn R. Practice indicators of suboptimal care and avoidable adverse events: a content analysis of a natio…
-
psnet.ahrq.gov/issue/e-prescribing-and-adverse-drug-events-observational-study-medicare-part-d-population-diabetes
September 30, 2015 - Study
E-prescribing and adverse drug events: an observational study of the Medicare Part D population with diabetes.
Citation Text:
Gabriel MH, Powers C, Encinosa W, et al. E-Prescribing and Adverse Drug Events: An Observational Study of the Medicare Part D Population With Diabetes. Med …
-
psnet.ahrq.gov/issue/learning-preventable-adverse-events-health-care-organizations-development-multilevel-model
June 28, 2010 - Commentary
Learning from preventable adverse events in health care organizations: development of a multilevel model of learning and propositions.
Citation Text:
Chuang Y-T, Ginsburg LR, Berta WB. Learning from preventable adverse events in health care organizations: development of a mu…
-
psnet.ahrq.gov/issue/human-factors-engineering-tool-medical-device-evaluation-hospital-procurement-decision-making
June 28, 2017 - Study
Human factors engineering: a tool for medical device evaluation in hospital procurement decision-making.
Citation Text:
Ginsburg G. Human factors engineering: a tool for medical device evaluation in hospital procurement decision-making. J Biomed Inform. 2005;38(3):213-9.
Copy C…
-
psnet.ahrq.gov/issue/complexity-medication-related-verbal-orders
November 17, 2010 - Study
Complexity of medication-related verbal orders.
Citation Text:
Wakefield DS, Ward MM, Groath D, et al. Complexity of medication-related verbal orders. Am J Med Qual. 2008;23(1):7-17. doi:10.1177/1062860607310922.
Copy Citation
Format:
DOI Google Scholar PubMed BibTe…
-
psnet.ahrq.gov/issue/department-medicine-infrastructure-patient-safety-and-clinical-quality-improvement
July 01, 2017 - Review
A Department of Medicine infrastructure for patient safety and clinical quality improvement.
Citation Text:
Mathews SC, Pronovost P, Biddison LD, et al. A Department of Medicine Infrastructure for Patient Safety and Clinical Quality Improvement. Am J Med Qual. 2018;33(4):413-419. …
-
psnet.ahrq.gov/node/859347/psn-pdf
December 20, 2023 - Making surgery as safe as it should be: a qualitative
study.
December 20, 2023
Robinson DJ, Beaumont G. Making surgery as safe as it should be: a qualitative study. Am J Med Qual.
2023;38(5):238-244. doi:10.1097/jmq.0000000000000139.
https://psnet.ahrq.gov/issue/making-surgery-safe-it-should-be-qualitative-study
…
-
psnet.ahrq.gov/issue/incidence-adverse-drug-events-and-potential-adverse-drug-events-implications-prevention
February 10, 2011 - Study
Classic
Incidence of adverse drug events and potential adverse drug events: implications for prevention.
Citation Text:
Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. …
-
psnet.ahrq.gov/node/46397/psn-pdf
August 30, 2017 - Making Dialysis Safer for Patients Coalition.
August 30, 2017
Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/making-dialysis-safer-patients-coalition
Dialysis is a common procedure that carries risks if not performed correctly. This initiative represents a
collective effort that aims to d…