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psnet.ahrq.gov/node/43340/psn-pdf
July 23, 2014 - Do doctors understand test results?
July 23, 2014
Kremer W.
https://psnet.ahrq.gov/issue/do-doctors-understand-test-results
This magazine article reports how weaknesses in physician understanding of statistics can lead to poorly
informed discussions with patients about risks and treatment options. Using actual num…
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psnet.ahrq.gov/node/33784/psn-pdf
April 01, 2015 - There was a very slight apparent improvement,
but it didn't meet the bar of statistical significance … We did not find a statistical
improvement in death and complications, or in other health service use … When we
tried to replicate that, not a single hospital in the Province had a statistical reduction in
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - track innovation progress and to address any challenges discovered during implementation 4
Conduct statistical … track innovation progress and to address any challenges discovered during implementation 4
Conduct statistical
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psnet.ahrq.gov/node/38477/psn-pdf
October 03, 2017 - Serious Adverse Events Reports.
October 3, 2017
The Quality Improvement Committee. Wellington, New Zealand; 2006-2013.
https://psnet.ahrq.gov/issue/serious-adverse-events-reports
Considered a starting point for a national reporting initiative, this series of annual reports provides statistics
on serious and sentin…
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psnet.ahrq.gov/node/60064/psn-pdf
March 18, 2020 - Providing Safe, High-Quality Maternity Care in Rural US
Hospitals. IHI Innovation Report.
March 18, 2020
Laderman M, Renton M. Boston, MA: Institute for Healthcare Improvement; 2020.
https://psnet.ahrq.gov/issue/providing-safe-high-quality-maternity-care-rural-us-hospitals-ihi-innovation-
report
Maternal care saf…
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psnet.ahrq.gov/node/847040/psn-pdf
April 05, 2023 - Communicating patient safety information through video
and oral formats-a comparison.
April 5, 2023
Bånnsgård M, Nouri A, Finizia C, et al. Communicating patient safety information through video and oral
formats-a comparison. J Patient Saf. 2023;19(2):137-142. doi:10.1097/pts.0000000000001086.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/50731/psn-pdf
December 11, 2019 - Awareness of diagnosis and follow up care after
discharge from the emergency department
December 11, 2019
Leamy K, Thompson J, Mitra B. Awareness of diagnosis and follow up care after discharge from the
Emergency Department. Australas Emerg Care. 2019;22(4):221-226. doi:10.1016/j.auec.2019.08.004.
https://psnet.ah…
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psnet.ahrq.gov/node/50629/psn-pdf
November 06, 2019 - Lack of association between intraoperative handoff of
care and postoperative complications: a retrospective
observational study.
November 6, 2019
O'Reilly-Shah VN, Melanson VG, Sullivan CL, et al. Lack of association between intraoperative handoff of
care and postoperative complications: a retrospective observatio…
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psnet.ahrq.gov/node/36286/psn-pdf
September 20, 2006 - The Health Literacy of America's Adults: Results from the
2003 National Assessment of Adult Literacy.
September 20, 2006
Kutner M, Greenberg E, Jin Y, et al. Washington, DC: National Center for Education Statistics; 2006.
https://psnet.ahrq.gov/issue/health-literacy-americas-adults-results-2003-national-assessment…
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psnet.ahrq.gov/node/38769/psn-pdf
July 08, 2009 - Nearly 90 major medical mistakes logged at Utah
hospitals in 2008.
July 8, 2009
May H. Salt Lake Tribune. June 26, 2009.
https://psnet.ahrq.gov/issue/nearly-90-major-medical-mistakes-logged-utah-hospitals-2008
This news story discusses Utah sentinel event statistics and compares them with 2007 data.
https://psnet…
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psnet.ahrq.gov/node/836721/psn-pdf
March 09, 2022 - Sources of medication omissions among hospitalized
older adults with polypharmacy.
March 9, 2022
Shah AS, Hollingsworth EK, Shotwell MS, et al. Sources of medication omissions among hospitalized older
adults with polypharmacy. J Am Geriatr Soc. 2022;70(4):1180-1189. doi:10.1111/jgs.17629.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/852802/psn-pdf
August 23, 2023 - Indian Health Service: Actions Needed to Improve Use of
Data on Adverse Events.
August 23, 2023
Washington, DC: United States Government Accounting Office; July 10, 2023. Publication GAO-23-
105722.
https://psnet.ahrq.gov/issue/indian-health-service-actions-needed-improve-use-data-adverse-events
Health info…
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psnet.ahrq.gov/node/73487/psn-pdf
July 14, 2021 - The July Effect in podiatric medicine and surgery
residency.
July 14, 2021
Casciato DJ, Thompson J, Law R, et al. The July Effect in podiatric medicine and surgery residency. J Foot
Ankle Surg. 2021;60(6):1152-1157. doi:10.1053/j.jfas.2021.04.020.
https://psnet.ahrq.gov/issue/july-effect-podiatric-medicine-and-sur…
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psnet.ahrq.gov/node/73700/psn-pdf
September 15, 2021 - Preliminary study of patient safety and quality use cases
for ICD-11 MMS.
September 15, 2021
Fenton SH, Giannangelo KL, Stanfill MH. Preliminary study of patient safety and quality use cases for ICD-
11 MMS. J Am Med Inform Assoc. 2021;28(11):2346-2353. doi:10.1093/jamia/ocab163.
https://psnet.ahrq.gov/issue/preli…
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psnet.ahrq.gov/node/50753/psn-pdf
December 18, 2019 - The contribution of staffing to medication administration
errors: a text mining analysis of incident report data.
December 18, 2019
Härkänen M, Vehviläinen?Julkunen K, Murrells T, et al. The Contribution of Staffing to Medication
Administration Errors: A Text Mining Analysis of Incident Report Data. J Nurs Scholars…
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psnet.ahrq.gov/node/60684/psn-pdf
January 01, 2021 - Post-discharge adverse events among African American
and Caucasian patients of an urban community hospital.
July 15, 2020
Costello WG, Zhang L, Schnipper JL, et al. Post-discharge adverse events among African American and
Caucasian patients of an urban community hospital. J Racial Ethn Health Disparities. 2021;8(2)…
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psnet.ahrq.gov/node/862128/psn-pdf
February 07, 2024 - Embracing the future-is artificial intelligence already
better? A comparative study of artificial intelligence
performance in diagnostic accuracy and decision-making.
February 7, 2024
Fonseca Â, Ferreira A, Ribeiro L, et al. Embracing the future—is artificial intelligence already better? A
comparative study of art…
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psnet.ahrq.gov/node/865973/psn-pdf
May 29, 2024 - Physician antipsychotic overprescribing letters and
cognitive, behavioral, and physical health outcomes
among people with dementia: a secondary analysis of a
randomized clinical trial.
May 29, 2024
Harnisch M, Barnett ML, Coussens S, et al. Physician antipsychotic overprescribing letters and cognitive,
behavioral…
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psnet.ahrq.gov/node/867091/psn-pdf
November 06, 2024 - Initiative to deprescribe high-risk drugs for older adults
presenting to the emergency department after falls.
November 6, 2024
Selman K, Roberts E, Niznik J, et al. Initiative to deprescribe high?risk drugs for older adults presenting to
the emergency department after falls. J Am Geriatr Soc. 2024;72(Supp 3):s60-s…
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psnet.ahrq.gov/node/866583/psn-pdf
August 28, 2024 - Assessing the STOPS framework for coping with
intraoperative errors: evidence of efficacy, hints of hubris,
and a bridge to abridging burnout.
August 28, 2024
D'Angelo JD, Rivera M, Rasmussen TE, et al. Assessing the stops framework for coping with intraoperative
errors: evidence of efficacy, hints of hubris, and …