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psnet.ahrq.gov/node/855088/psn-pdf
January 01, 2024 - Impact of hospital-acquired pneumonia on the Medicare
program.
November 8, 2023
Baker DL, Giuliano KK, Desmarais M, et al. Impact of hospital-acquired pneumonia on the Medicare
program. Infect Control Hosp Epidemiol. 2024;45(3):316-321. doi:10.1017/ice.2023.221.
https://psnet.ahrq.gov/issue/impact-hospital-acquire…
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psnet.ahrq.gov/node/39023/psn-pdf
November 19, 2018 - Pediatric Readiness in the Emergency Department.
November 19, 2018
Remick K, Gausche-Hill M, Joseph MM, et al. Pediatric Readiness in the Emergency Department.
Pediatrics. 2018;142(5):e20182459. doi:10.1542/peds.2018-2459.
https://psnet.ahrq.gov/issue/pediatric-readiness-emergency-department
This revised set of gu…
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psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - updates (such as the transition from ICD-9-CM to ICD-10-CM), evidence from validation studies, and suggestions
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psnet.ahrq.gov/node/854989/psn-pdf
November 01, 2023 - Understanding the facilitators and barriers to barcode
medication administration by nursing staff using
behavioural science frameworks. A mixed methods study.
November 1, 2023
Grailey K, Hussain R, Wylleman E, et al. Understanding the facilitators and barriers to barcode medication
administration by nursing staff …
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psnet.ahrq.gov/node/852273/psn-pdf
August 09, 2023 - Experimental evidence for structured information-sharing
networks reducing medical errors.
August 9, 2023
Centola D, Becker J, Zhang J, et al. Experimental evidence for structured information–sharing networks
reducing medical errors. Proc Natl Acad Sci U S A. 2023;120(31):e2108290120.
doi:10.1073/pnas.2108290120.
…
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psnet.ahrq.gov/issue/missed-diagnoses-acute-myocardial-infarction-emergency-department-variation-patient-and
April 08, 2018 - Study
Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics.
Citation Text:
Moy E, Barrett M, Coffey R, et al. Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and fa…
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psnet.ahrq.gov/node/47615/psn-pdf
January 30, 2019 - A Crisis in Health Care: A Call to Action on Physician
Burnout.
January 30, 2019
Jha AK, Iliff AR, Chaoui AA, et al. Waltham, MA: Massachusetts Medical Society, Massachusetts Health
and Hospital Association, Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute;
2019.
https://psnet.ahrq.g…
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psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - A Mid-Summer Fog
Citation Text:
Braddock CH. A Mid-Summer Fog. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/838078/psn-pdf
September 14, 2022 - Patient safety issues from information overload in
electronic medical records.
September 14, 2022
Nijor S, Rallis G, Lad N, et al. Patient safety issues from information overload in electronic medical records.
J Patient Saf. 2022;18(6):e999-e1003. doi:10.1097/pts.0000000000001002.
https://psnet.ahrq.gov/issue/pati…
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psnet.ahrq.gov/node/73495/psn-pdf
July 14, 2021 - Implementation strategies in the context of medication
reconciliation: a qualitative study.
July 14, 2021
Stolldorf DP, Ridner SH, Vogus TJ, et al. Implementation strategies in the context of medication
reconciliation: a qualitative study. Implement Sci Commun. 2021;2(1):63. doi:10.1186/s43058-021-00162-5.
https:/…
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psnet.ahrq.gov/node/867750/psn-pdf
March 12, 2025 - Doing 'detective work' to find a cancer: how are non-
specific symptom pathways for cancer investigation
organised, and what are the implications for safety and
quality of care? A multisite qualitative approach.
March 12, 2025
Black GB, Nicholson BD, Moreland J-A, et al. Doing ‘detective work’ to find a cancer: ho…
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psnet.ahrq.gov/web-mm/neurological-red-flags-missed-stroke-after-intermittent-episodes-dizziness-and-headache
February 08, 2023 - SPOTLIGHT CASE
Neurological Red Flags: A Missed Stroke after Intermittent Episodes of Dizziness and Headache
Citation Text:
Edlow J. Neurological Red Flags: A Missed Stroke after Intermittent Episodes of Dizziness and Headache. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …
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psnet.ahrq.gov/node/837415/psn-pdf
June 15, 2022 - Instruments for measuring patient safety competencies in
nursing: a scoping review.
June 15, 2022
Mortensen M, Naustdal KI, Uibu E, et al. Instruments for measuring patient safety competencies in nursing:
a scoping review. BMJ Open Qual. 2022;11(2):e001751. doi:10.1136/bmjoq-2021-001751.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/60701/psn-pdf
July 22, 2020 - Prevalence and nature of medication errors and
medication-related harm following discharge from
hospital to community settings: a systematic review.
July 22, 2020
Alqenae FA, Steinke DT, Keers RN. Prevalence and nature of medication errors and medication-related
harm following discharge from hospital to community …
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psnet.ahrq.gov/node/61019/psn-pdf
October 14, 2020 - Clinical deterioration and hospital?acquired
complications in adult patients with isolation precautions
for infection control: a systematic review.
October 14, 2020
Berry D, Wakefield E, Street M, et al. Clinical deterioration and hospital?acquired complications in adult
patients with isolation precautions for inf…
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psnet.ahrq.gov/node/50746/psn-pdf
December 18, 2019 - The influence of organizational culture, climate and
commitment on speaking up about medical errors.
December 18, 2019
Levine KJ, Carmody M, Silk KJ. The influence of organizational culture, climate and commitment on
speaking up about medical errors. J Nurs Manag. 2019;28(1):130-138. doi:10.1111/jonm.12906.
https:…
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psnet.ahrq.gov/perspective/patient-engagement-safety
January 01, 2018 - Annual Perspective
Patient Engagement in Safety
Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2017
View more articles from the same authors.
Citation Text:
Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. Rockville (MD): Agency…
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psnet.ahrq.gov/web-mm/transfusion-overload
September 23, 2020 - Anesthesia in cases of poor surgical risk: some suggestions for decreasing the risk.
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psnet.ahrq.gov/node/48181/psn-pdf
August 07, 2019 - Managing the risks of direct oral anticoagulants.
August 7, 2019
Sentinel Event Alert. July 30, 2019;(61):1-5.
https://psnet.ahrq.gov/issue/managing-risks-direct-oral-anticoagulants
Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral
anticoagulants (DOACs) require less…
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psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy
November 25, 2020 - One systematic review identified 43 articles that included 6 tested interventions and 37 suggestions