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psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
December 08, 2021 - efficiency by allowing for economy of scale, whether utilizing a health system's own staff in a call-center type … misconstrued when clinicians are the only ones able to express themselves in an encounter, use of this type … depends on the infrastructure and resource of the particular health care environment as well as the type
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - Self-retaining soft tissue retractor systems of this type may cause traction or compression injury to … reinforced ETTs that have a metal wire embedded in the wall to prevent kinking are often used for this type … to be identified and treated Obese patients like the patient in this Commentary may have undiagnosed type
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psnet.ahrq.gov/issue/advanced-medication-reconciliation-systematic-review-impact-medication-errors-and-adverse
December 18, 2017 - Review
Advanced medication reconciliation: a systematic review of the impact on medication errors and adverse drug events associated with transitions of care.
Citation Text:
Killin L, Hezam A, Anderson KK, et al. Advanced medication reconciliation: a systematic review of the impact on me…
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psnet.ahrq.gov/issue/identifying-patient-safety-problems-associated-information-technology-general-practice
December 21, 2017 - Study
Identifying patient safety problems associated with information technology in general practice: an analysis of incident reports.
Citation Text:
Magrabi F, Liaw ST, Arachi D, et al. Identifying patient safety problems associated with information technology in general practice: an an…
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psnet.ahrq.gov/node/33592/psn-pdf
December 15, 2024 - Adverse Events, Near Misses, and Errors
December 15, 2024
Adverse Events, Near Misses, and Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current re…
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psnet.ahrq.gov/issue/debiasing-health-related-judgments-and-decision-making-systematic-review
January 04, 2010 - February 10, 2016
Frequency and type of situational awareness errors contributing to
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psnet.ahrq.gov/issue/association-polypharmacy-and-potential-drug-drug-interactions-adverse-treatment-outcomes
May 25, 2016 - Medication-related hospital readmissions within 30 days of discharge: prevalence, preventability, type
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psnet.ahrq.gov/issue/inpatient-suicide-preventing-common-sentinel-event
May 28, 2015 - Medication-related hospital readmissions within 30 days of discharge: prevalence, preventability, type
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psnet.ahrq.gov/issue/reporting-hazards-and-near-misses-ambulatory-care-setting
October 19, 2011 - March 24, 2021
Monitoring preventable adverse events and near misses: number and type
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psnet.ahrq.gov/issue/impact-individual-and-team-features-patient-safety-climate-survey-family-practices
January 08, 2014 - May 18, 2019
Safety climate and its association with office type and team involvement
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psnet.ahrq.gov/issue/dual-process-models-clinical-reasoning-central-role-knowledge-diagnostic-expertise
March 08, 2017 - Exploring the accuracy of the size and type of group diagnosis: an experimental study.
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psnet.ahrq.gov/issue/toward-zero-harm-mackenzie-healths-journey-toward-becoming-high-reliability-organization-and
September 14, 2022 - June 8, 2022
Monitoring preventable adverse events and near misses: number and type identified
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psnet.ahrq.gov/issue/prescribing-errors-post-covid-19-patients-prevalence-severity-and-risk-factors-patients
June 29, 2022 - Medication-related hospital readmissions within 30 days of discharge: prevalence, preventability, type
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psnet.ahrq.gov/node/867747/psn-pdf
March 12, 2025 - A framework for the analysis of communication errors in
health care.
March 12, 2025
Bender JA, Thiyagarajan S, Morrish W, et al. A framework for the analysis of communication errors in
health care. J Patient Saf. 2025;21(2):69-81. doi:10.1097/pts.0000000000001303.
https://psnet.ahrq.gov/issue/framework-analysis-co…
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psnet.ahrq.gov/issue/please-describe-your-point-view-typical-case-error-palliative-care-qualitative-data
December 04, 2016 - February 10, 2016
Frequency and type of situational awareness errors contributing to
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psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
November 30, 2023 - the basis for the choices made and actions taken in the case, those reasons were not necessarily the type … reasons, and that this case therefore serves as an example of an “order-of-reasons" problem: the wrong type … patient-centered care, health care organizations must have mechanisms in place to address controversies of the type
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psnet.ahrq.gov/node/72834/psn-pdf
March 10, 2021 - This type of inadequate communication at handoffs
contributes to adverse events, including medication
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psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety
October 24, 2021 - community pharmacies can be found, but whenever you think of a patient condition that requires any type … of medication therapy or any type of intervention within the community, you will likely find a pharmacy … called Assess-ERR™, and it guides you through how to document the error or near-miss to understand what type … So, it's all on a case-by-case basis, depending on what type of error you're seeing.
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psnet.ahrq.gov/node/33600/psn-pdf
June 16, 2024 - Patient Safety 101
June 16, 2024
Patient Safety 101. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-safety-101
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in…
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psnet.ahrq.gov/periodic-issue/weekly-resource
March 25, 2025 - Using three triggers and the Revised Safer Dx Instrument, this study uncovered the frequency, type, causative