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psnet.ahrq.gov/issue/deficiencies-after-new-electronic-health-record-go-live-mann-grandstaff-va-medical-center
March 16, 2022 - Book/Report
Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.
Citation Text:
Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA. Washington, DC: VA Office o…
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psnet.ahrq.gov/issue/effect-health-care-working-conditions-patient-safety-evidence-reporttechnology-assessment
December 18, 2008 - Book/Report
The Effect of Health Care Working Conditions on Patient Safety. Evidence Report/Technology Assessment.
Citation Text:
The Effect of Health Care Working Conditions on Patient Safety. Evidence Report/Technology Assessment. Rockville, MD: Agency for Healthcare Research and Quali…
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psnet.ahrq.gov/node/34753/psn-pdf
March 28, 2005 - Report on the Medical Insurance Feasibility Study.
March 28, 2005
Mills DH. San Francisco, CA: California Medical Association; 1977.
https://psnet.ahrq.gov/issue/report-medical-insurance-feasibility-study
Escalating professional liability costs prompted this study on the nature of adverse outcomes related to
medic…
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psnet.ahrq.gov/issue/deficiencies-quality-management-processes-and-delays-communication-test-results-and-follow
March 01, 2023 - Book/Report
Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.
Citation Text:
Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Fol…
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psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-diagnosed-prostate-cancer-hampton-va-medical
July 26, 2023 - Book/Report
Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.
Citation Text:
Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in V…
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psnet.ahrq.gov/issue/evaluation-electronic-health-record-structured-discharge-summary-provide-real-time-adverse
December 29, 2014 - Study
Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery.
Citation Text:
Graham AJ, Ocampo W, Southern DA, et al. Evaluation of an electronic health record structured discharge summary to provide real ti…
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psnet.ahrq.gov/issue/communicating-clearly-about-medicines-proceedings-workshop
September 12, 2018 - Meeting/Conference Proceedings
Communicating Clearly About Medicines: Proceedings of a Workshop.
Citation Text:
Communicating Clearly About Medicines: Proceedings of a Workshop. National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press: 2017.…
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psnet.ahrq.gov/issue/future-nursing-leading-change-advancing-health
July 27, 2011 - Book/Report
The Future of Nursing: Leading Change, Advancing Health.
Citation Text:
The Future of Nursing: Leading Change, Advancing Health. Institute of Medicine. Washington, DC: The National Academies Press: 2011.
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psnet.ahrq.gov/web-mm/dressed-failure
September 01, 2011 - physicians includes medication data, laboratory data, imaging files, clinical documentation, discharge summaries
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psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
January 07, 2015 - Misconnection Leading to Arterial Thrombosis
June 28, 2023
Danger in discharge summaries
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psnet.ahrq.gov/node/49612/psn-pdf
November 01, 2010 - Adequacy of hospital discharge summaries in documenting tests with
pending results and outpatient follow-up
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psnet.ahrq.gov/web-mm/hold-order
December 19, 2018 - These summaries could include both active and recently discontinued medications.
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psnet.ahrq.gov/issue/expressing-concern-and-writing-it-down-experimental-study-investigating-transfer-information
November 17, 2014 - Study
Expressing concern and writing it down: an experimental study investigating transfer of information at nursing handover.
Citation Text:
Lee H, Cumin D, Devcich DA, et al. Expressing concern and writing it down: an experimental study investigating transfer of information at nursing …
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psnet.ahrq.gov/issue/reducing-and-preventing-adverse-drug-events-decrease-hospital-costs
March 05, 2013 - Government Resource
Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs.
Citation Text:
Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs. Research in Action, Issue 1. Rockville, MD: Agency for Healthcare Research and Quality; March 2001. AHRQ …
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psnet.ahrq.gov/issue/ranking-rate-state-medical-boards-serious-disciplinary-actions-2019-2021
October 05, 2016 - Book/Report
Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2019-2021.
Citation Text:
Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2019-2021. Wolfe SW, Oshel RE. Washington, DC: Public Citizen; August 16, 2023.
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)
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psnet.ahrq.gov/node/45683/psn-pdf
January 23, 2017 - Consensus bundle on prevention of surgical site
infections after major gynecologic surgery.
January 23, 2017
Pellegrini JE, Toledo P, Soper DE, et al. Consensus Bundle on Prevention of Surgical Site Infections After
Major Gynecologic Surgery. Obstet Gynecol. 2017;129(1):50-61. doi:10.1097/AOG.0000000000001751.
htt…
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psnet.ahrq.gov/node/46513/psn-pdf
June 19, 2018 - Development of a trigger tool to identify adverse events
and no-harm incidents that affect patients admitted to
home healthcare.
June 19, 2018
Lindblad M, Schildmeijer K, Nilsson L, et al. Development of a trigger tool to identify adverse events and
no-harm incidents that affect patients admitted to home healthcar…
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psnet.ahrq.gov/issue/keeping-patients-safe-transforming-work-environment-nurses
July 05, 2016 - Book/Report
Classic
Keeping Patients Safe: Transforming the Work Environment of Nurses.
Citation Text:
Keeping Patients Safe: Transforming the Work Environment of Nurses. Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Healt…
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psnet.ahrq.gov/node/73300/psn-pdf
July 01, 2022 - Additionally, discharge summaries often lack important information
or may be unavailable when patients