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psnet.ahrq.gov/node/841773/psn-pdf
December 21, 2022 - Inappropriate prescribing of opioids for patients
undergoing surgery.
December 21, 2022
Varady NH, Worsham CM, Chen AF, et al. Inappropriate prescribing of opioids for patients undergoing
surgery. Proc Natl Acad Sci USA. 2022;119(49):e2210226119. doi:10.1073/pnas.2210226119.
https://psnet.ahrq.gov/issue/inappropri…
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psnet.ahrq.gov/node/47999/psn-pdf
May 15, 2019 - Pregnancy-related deaths: saving women’s lives before,
during and after delivery.
May 15, 2019
CDC Vital Signs. May 7, 2019.
https://psnet.ahrq.gov/issue/pregnancy-related-deaths-saving-womens-lives-during-and-after-delivery
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis desc…
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psnet.ahrq.gov/node/39207/psn-pdf
May 24, 2015 - An In Depth Investigation into Causes of Prescribing
Errors by Foundation Trainees in Relation to Their
Medical Education—EQUIP Study.
May 24, 2015
Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.
https://psnet.ahrq.gov/issue/depth-investigation-causes-prescribing-errors-foundation…
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psnet.ahrq.gov/node/34912/psn-pdf
February 03, 2010 - Disruptive behavior and clinical outcomes: perceptions of
nurses and physicians.
February 3, 2010
Rosenstein AH, O'Daniel M. Disruptive behavior and clinical outcomes: perceptions of nurses and
physicians. Am J Nurs. 2005;105(1):54-64; quiz 64-5.
https://psnet.ahrq.gov/issue/disruptive-behavior-and-clinical-outcom…
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psnet.ahrq.gov/node/41625/psn-pdf
December 02, 2014 - Effects of CPOE on provider cognitive workload: a
randomized crossover trial.
December 2, 2014
Avansino J, Leu MG. Effects of CPOE on provider cognitive workload: a randomized crossover trial.
Pediatrics. 2012;130(3):e547-52. doi:10.1542/peds.2011-3408.
https://psnet.ahrq.gov/issue/effects-cpoe-provider-cognitive-…
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psnet.ahrq.gov/node/36532/psn-pdf
March 28, 2011 - A theory-based instrument to evaluate team
communication in the operating room: balancing
measurement authenticity and reliability.
March 28, 2011
Lingard LA, Regehr G, Espin S, et al. A theory-based instrument to evaluate team communication in the
operating room: balancing measurement authenticity and reliability…
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psnet.ahrq.gov/node/39085/psn-pdf
November 11, 2009 - Integrating ethics and patient safety: the role of clinical
ethics consultants in quality improvement.
November 11, 2009
Opel DJ, Brownstein D, Diekema DS, et al. Integrating ethics and patient safety: the role of clinical ethics
consultants in quality improvement. J Clin Ethics. 2009;20(3):220-6.
https://psnet.ah…
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psnet.ahrq.gov/node/40447/psn-pdf
March 04, 2015 - Analysis and prioritization of near-miss adverse events in
a radiology department.
March 4, 2015
Thornton RH, Miransky J, Killen A, et al. Analysis and prioritization of near-miss adverse events in a
radiology department. AJR Am J Roentgenol. 2011;196(5):1120-4. doi:10.2214/AJR.10.5373.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/42387/psn-pdf
December 30, 2014 - 'Bad apples': time to redefine as a type of systems
problem?
December 30, 2014
Shojania KG, Dixon-Woods M. 'Bad apples': time to redefine as a type of systems problem? BMJ Qual Saf.
2013;22(7):528-531. doi:10.1136/bmjqs-2013-002138.
https://psnet.ahrq.gov/issue/bad-apples-time-redefine-type-systems-problem
While …
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psnet.ahrq.gov/node/45587/psn-pdf
January 23, 2017 - Comparison of physician and computer diagnostic
accuracy.
January 23, 2017
Semigran HL, Levine DM, Nundy S, et al. Comparison of Physician and Computer Diagnostic Accuracy.
JAMA Intern Med. 2016;176(12):1860-1861. doi:10.1001/jamainternmed.2016.6001.
https://psnet.ahrq.gov/issue/comparison-physician-and-computer-d…
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psnet.ahrq.gov/node/837001/psn-pdf
April 27, 2022 - Final Report of the Ockenden Review.
April 27, 2022
London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294.
https://psnet.ahrq.gov/issue/final-report-ockenden-review
Maternal and baby harm in healthcare is a sentinel event manifested by systemic failure. This report serves
as the final conclusions of an i…
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psnet.ahrq.gov/node/47765/psn-pdf
February 20, 2019 - Negative behaviours in health care: prevalence and
strategies.
February 20, 2019
Layne DM, Nemeth LS, Mueller M, et al. Negative behaviours in health care: Prevalence and strategies. J
Nurs Manag. 2019;27(1):154-160. doi:10.1111/jonm.12660.
https://psnet.ahrq.gov/issue/negative-behaviours-health-care-prevalence-an…
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psnet.ahrq.gov/node/45427/psn-pdf
October 19, 2016 - How to monitor patient safety in primary care? Healthcare
professionals' views.
October 19, 2016
Samra R, Car J, Majeed A, et al. How to monitor patient safety in primary care? Healthcare professionals'
views. JRSM Open. 2016;7(8):2054270416648045. doi:10.1177/2054270416648045.
https://psnet.ahrq.gov/issue/how-mon…
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psnet.ahrq.gov/node/836832/psn-pdf
March 30, 2022 - Improving Education—A Key to Better Diagnostic
Outcomes.
March 30, 2022
Olson APJ, Danielson J, Stanley J, et al. Rockville, MD: Agency for Healthcare Research and Quality;
March 2022. AHRQ Publication No. 22-0026-1-EF
https://psnet.ahrq.gov/issue/improving-education-key-better-diagnostic-outcomes
Diagnostic skil…
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psnet.ahrq.gov/node/47321/psn-pdf
June 19, 2019 - Validation of a mobile app for reducing errors of
administration of medications in an emergency.
June 19, 2019
Baumann D, Dibbern N, Sehner S, et al. Validation of a mobile app for reducing errors of administration of
medications in an emergency. J Clin Monit Comput. . 2019;33(3):531-539. doi:10.1007/s10877-018-018…
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psnet.ahrq.gov/node/37479/psn-pdf
February 22, 2011 - Performance of a web-based clinical diagnosis support
system for internists.
February 22, 2011
Graber ML, Mathew A. Performance of a web-based clinical diagnosis support system for internists. J Gen
Intern Med. 2008;23 Suppl 1:37-40. doi:10.1007/s11606-007-0271-8.
https://psnet.ahrq.gov/issue/performance-web-based…
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psnet.ahrq.gov/node/42929/psn-pdf
February 05, 2014 - Do no harm: is it time to rethink the Hippocratic Oath?
February 5, 2014
Walton M, Kerridge I. Do no harm: is it time to rethink the Hippocratic Oath? Med Educ. 2014;48(1):17-27.
doi:10.1111/medu.12275.
https://psnet.ahrq.gov/issue/do-no-harm-it-time-rethink-hippocratic-oath
This commentary discusses how health ca…
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psnet.ahrq.gov/node/35039/psn-pdf
February 24, 2019 - Managing unnecessary variability in patient demand to
reduce nursing stress and improve patient safety.
February 24, 2019
Litvak E, Buerhaus P, Davidoff F, et al. Managing unnecessary variability in patient demand to reduce
nursing stress and improve patient safety. Jt Comm J Qual Patient Saf. 2005;31(6):330-8.
ht…
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psnet.ahrq.gov/node/35073/psn-pdf
January 01, 2016 - The role of teamwork in the professional education of
physicians: current status and assessment
recommendations.
March 29, 2007
Baker DP, Salas E, King HB, et al. The Role of Teamwork in the Professional Education of Physicians:
Current Status and Assessment Recommendations. Jt Comm J Qual Patient Saf. 2016;31(4):…
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psnet.ahrq.gov/node/46729/psn-pdf
January 17, 2018 - Diagnostic error in pediatric cancer.
January 17, 2018
Carberry AR, Hanson K, Flannery A, et al. Diagnostic Error in Pediatric Cancer. Clin Pediatr (Phila).
2017;57*1((1):11-18. doi:10.1177/0009922816687325.
https://psnet.ahrq.gov/issue/diagnostic-error-pediatric-cancer
Missed or delayed cancer diagnoses can lead …