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  1. Learning from different lenses: reports of medical errors in primary care by clinicians, staff, and patients: a project of the American Academy of Family Physicians National Research Network. | PSNet

    psnet.ahrq.gov/issue/learning-different-lenses-reports-medical-errors-primary-care-clinicians-staff-and-patients
    June 11, 2008 - Study Learning from different lenses: reports of medical errors in primary care by clinicians, staff, and patients: a project of the American Academy of Family Physicians National Research Network. Citation Text: Phillips RL, Dovey SM, Graham D, et al. Learning From Different Lenses: R…

  2. Zoom Webinar Instructions (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/news/events/nac/instructions-zoom.pdf
    June 02, 2025 - Zoom Webinar Instructions Zoom Webinar Instructions Please note that attendees will not be able to use their personal video during the AHRQ NAC Meeting, and there will be no chat or Q&A option. Should you have any technical problems or questions before/during the meeting, please contact Amy Rabin at amy.rabin…

  3. National trends in hospital-acquired preventable adverse events after major cancer surgery in the USA. | PSNet

    psnet.ahrq.gov/issue/national-trends-hospital-acquired-preventable-adverse-events-after-major-cancer-surgery-usa
    September 12, 2016 - Study National trends in hospital-acquired preventable adverse events after major cancer surgery in the USA. Citation Text: Sukumar S, Roghmann F, Trinh VQ, et al. National trends in hospital-acquired preventable adverse events after major cancer surgery in the USA. BMJ Open. 2013;3(6)…

  4. Use of pediatric injectable medicines guidelines and associated medication administration errors: a human reliability analysis. | PSNet

    psnet.ahrq.gov/issue/use-pediatric-injectable-medicines-guidelines-and-associated-medication-administration-errors
    December 18, 2019 - Study Use of pediatric injectable medicines guidelines and associated medication administration errors: a human reliability analysis. Citation Text: Jones MD, Clarke J, Feather C, et al. Use of pediatric injectable medicines guidelines and associated medication administration errors: a h…

  5. Using coworker observations to promote accountability for disrespectful and unsafe behaviors by physicians and advanced practice professionals. | PSNet

    psnet.ahrq.gov/issue/using-coworker-observations-promote-accountability-disrespectful-and-unsafe-behaviors
    June 27, 2018 - Study Using coworker observations to promote accountability for disrespectful and unsafe behaviors by physicians and advanced practice professionals. Citation Text: Webb LE, Dmochowski RR, Moore IN, et al. Using Coworker Observations to Promote Accountability for Disrespectful and Unsafe…

  6. Clinical impact and frequency of anatomic pathology errors in cancer diagnoses. | PSNet

    psnet.ahrq.gov/issue/clinical-impact-and-frequency-anatomic-pathology-errors-cancer-diagnoses
    March 28, 2012 - Study Classic Clinical impact and frequency of anatomic pathology errors in cancer diagnoses. Citation Text: Raab SS, Grzybicki DM, Janosky JE, et al. Clinical impact and frequency of anatomic pathology errors in cancer diagnoses. Cancer. 2005;104(10):2205-13.…

  7. Unplanned early hospital readmission among critical care survivors: a mixed methods study of patients and carers. | PSNet

    psnet.ahrq.gov/issue/unplanned-early-hospital-readmission-among-critical-care-survivors-mixed-methods-study
    September 23, 2020 - Study Unplanned early hospital readmission among critical care survivors: a mixed methods study of patients and carers. Citation Text: Donaghy E, Salisbury L, Lone NI, et al. Unplanned early hospital readmission among critical care survivors: a mixed methods study of patients and carers.…

  8. Electronic health record–related events in medical malpractice claims. | PSNet

    psnet.ahrq.gov/issue/electronic-health-record-related-events-medical-malpractice-claims
    April 03, 2018 - Study Classic Electronic health record–related events in medical malpractice claims. Citation Text: Graber ML, Siegal D, Riah H, et al. Electronic Health Record-Related Events in Medical Malpractice Claims. J Patient Saf. 2019;15(2):77-85. doi:10.1097/PTS.000000…

  9. Interventions to address potentially inappropriate prescribing in community-dwelling older adults: a systematic review of randomized controlled trials. | PSNet

    psnet.ahrq.gov/issue/interventions-address-potentially-inappropriate-prescribing-community-dwelling-older-adults
    August 14, 2024 - Review Interventions to address potentially inappropriate prescribing in community-dwelling older adults: a systematic review of randomized controlled trials. Citation Text: Clyne B, Fitzgerald C, Quinlan A, et al. Interventions to Address Potentially Inappropriate Prescribing in Communi…

  10. Explaining the negative effects of patient participation in patient safety: an exploratory qualitative study in an academic tertiary healthcare centre in the Netherlands. | PSNet

    psnet.ahrq.gov/issue/explaining-negative-effects-patient-participation-patient-safety-exploratory-qualitative
    November 04, 2020 - Study Explaining the negative effects of patient participation in patient safety: an exploratory qualitative study in an academic tertiary healthcare centre in the Netherlands. Citation Text: Van der Voorden M, Ahaus K, Franx A. Explaining the negative effects of patient participation in…

  11. Readmission after delayed diagnosis of surgical site infection: a focus on prevention using the American College of Surgeons National Surgical Quality Improvement Program. | PSNet

    psnet.ahrq.gov/issue/readmission-after-delayed-diagnosis-surgical-site-infection-focus-prevention-using-american
    September 22, 2021 - Study Readmission after delayed diagnosis of surgical site infection: a focus on prevention using the American College of Surgeons National Surgical Quality Improvement Program. Citation Text: Gibson A, Tevis S, Kennedy G. Readmission after delayed diagnosis of surgical site infection: a…

  12. Association of rapid response teams with hospital mortality in Medicare patients. | PSNet

    psnet.ahrq.gov/issue/association-rapid-response-teams-hospital-mortality-medicare-patients
    September 23, 2020 - Study Association of rapid response teams with hospital mortality in Medicare patients. Citation Text: Girotra S, Jones PG, Peberdy MA, et al. Association of rapid response teams with hospital mortality in Medicare patients. Circ Cardiovasc Qual Outcomes. 2022;15(9):e008901. doi:10.1161/…

  13. Temporal trends in patient safety in the Netherlands: reductions in preventable adverse events or the end of adverse events as a useful metric? | PSNet

    psnet.ahrq.gov/issue/temporal-trends-patient-safety-netherlands-reductions-preventable-adverse-events-or-end
    June 30, 2021 - Commentary Temporal trends in patient safety in the Netherlands: reductions in preventable adverse events or the end of adverse events as a useful metric? Citation Text: Shojania KG, van de Mheen PJM-. Temporal trends in patient safety in the Netherlands: reductions in preventable advers…

  14. 'Poking the skunk': ethical and medico-legal concerns in research about patients' experiences of medical injury. | PSNet

    psnet.ahrq.gov/issue/poking-skunk-ethical-and-medico-legal-concerns-research-about-patients-experiences-medical
    May 05, 2021 - Commentary 'Poking the skunk': ethical and medico-legal concerns in research about patients' experiences of medical injury. Citation Text: Moore JS, Mello MM, Bismark M. 'Poking the skunk': Ethical and medico-legal concerns in research about patients' experiences of medical injury. Bioet…

  15. Emergency department contribution to the prescription opioid epidemic. | PSNet

    psnet.ahrq.gov/issue/emergency-department-contribution-prescription-opioid-epidemic
    June 21, 2016 - Study Classic Emergency department contribution to the prescription opioid epidemic. Citation Text: Axeen S, Seabury SA, Menchine M. Emergency Department Contribution to the Prescription Opioid Epidemic. Ann Emerg Med. 2018;71(6):659-667.e3. doi:10.1016/j.anneme…

  16. Purchase of prescription medicines via social media: a survey-based study of prevalence, risk perceptions, and motivations. | PSNet

    psnet.ahrq.gov/issue/purchase-prescription-medicines-social-media-survey-based-study-prevalence-risk-perceptions
    May 19, 2021 - Study Purchase of prescription medicines via social media: a survey-based study of prevalence, risk perceptions, and motivations. Citation Text: Moureaud C, Hertig JB, Dong Y, et al. Purchase of prescription medicines via social media: a survey-based study of prevalence, risk perceptions…

  17. Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit. | PSNet

    psnet.ahrq.gov/issue/adverse-events-experienced-while-transferring-critically-ill-patient-emergency-department
    November 13, 2024 - Study Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit. Citation Text: Gillman L, Leslie G, Williams T, et al. Adverse events experienced while transferring the critically ill patient from the emergency de…

  18. TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents? | PSNet

    psnet.ahrq.gov/issue/triad-vii-do-prehospital-providers-understand-physician-orders-life-sustaining-treatment
    September 15, 2021 - Study TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents? Citation Text: Mirarchi FL, Cammarata C, Zerkle SW, et al. TRIAD VII: do prehospital providers understand Physician Orders for Life-Sustaining Treatment documents? J Patient Saf…

  19. Defining near misses: towards a sharpened definition based on empirical data about error handling processes. | PSNet

    psnet.ahrq.gov/issue/defining-near-misses-towards-sharpened-definition-based-empirical-data-about-error-handling
    June 28, 2011 - Study Defining near misses: towards a sharpened definition based on empirical data about error handling processes. Citation Text: Kessels-Habraken M, Van der Schaaf T, De Jonge J, et al. Defining near misses: towards a sharpened definition based on empirical data about error handling pr…

  20. Comparison of medication safety effectiveness among nine critical access hospitals. | PSNet

    psnet.ahrq.gov/issue/comparison-medication-safety-effectiveness-among-nine-critical-access-hospitals
    September 07, 2022 - Study Comparison of medication safety effectiveness among nine critical access hospitals. Citation Text: Cochran GL, Haynatzki G. Comparison of medication safety effectiveness among nine critical access hospitals. Am J Health Syst Pharm. 2013;70(24):2218-24. doi:10.2146/ajhp130067. Co…
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