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psnet.ahrq.gov/issue/designing-human-centered-ai-prevent-medication-dispensing-errors-focus-group-study
August 31, 2022 - Study
Designing human-centered AI to prevent medication dispensing errors: focus group study with pharmacists.
Citation Text:
Zheng Y, Rowell B, Chen Q, et al. Designing human-centered AI to prevent medication dispensing errors: focus group study with pharmacists. JMIR Form Res. 2023;7:e…
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psnet.ahrq.gov/issue/missing-near-miss-recognizing-valuable-learning-opportunities-radiation-oncology
November 18, 2020 - Study
Missing the near miss: recognizing valuable learning opportunities in radiation oncology.
Citation Text:
Kundu P, Jung OS, Valle LF, et al. Missing the near miss: recognizing valuable learning opportunities in radiation oncology. Pract Radiat Oncol. 2021;11(3):e256-e262. doi:10.101…
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psnet.ahrq.gov/issue/improving-quality-insulin-prescribing-people-diabetes-being-discharged-hospital
November 16, 2022 - Journal Article
Improving the quality of insulin prescribing for people with diabetes being discharged from hospital
Citation Text:
Bain A, Silcock J, Kavanagh S, et al. Improving the quality of insulin prescribing for people with diabetes being discharged from hospital. BMJ Open Qual. 2…
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psnet.ahrq.gov/issue/performance-variability-perioperative-sentinel-events-report-nationwide-data-set
November 04, 2020 - Study
Performance variability in perioperative sentinel events: report on a nationwide data set.
Citation Text:
Reijmerink IM, Bos K, Leistikow IP, et al. Performance variability in perioperative sentinel events: report on a nationwide data set. Br J Surg. 2022;109(7):573-575. doi:10.109…
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psnet.ahrq.gov/issue/adverse-events-anesthesia-integrative-review
October 16, 2024 - Review
Adverse Events in Anesthesia: An Integrative Review.
Citation Text:
Lemos C de S, Poveda V de B. Adverse Events in Anesthesia: An Integrative Review. J Perianesth Nurs. 2019;34(5):978-998. doi:10.1016/j.jopan.2019.02.005.
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psnet.ahrq.gov/issue/injury-and-liability-associated-monitored-anesthesia-care-closed-claims-analysis
June 23, 2009 - Study
Injury and liability associated with monitored anesthesia care: a closed claims analysis.
Citation Text:
Bhananker SM, Posner KL, Cheney FW, et al. Injury and liability associated with monitored anesthesia care: a closed claims analysis. Anesthesiology. 2006;104(2):228-234.
Cop…
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psnet.ahrq.gov/issue/how-health-care-systems-let-our-patients-down-systematic-review-suicide-deaths
October 19, 2022 - Review
How health care systems let our patients down: a systematic review into suicide deaths.
Citation Text:
Wyder M, Ray MK, Roennfeldt H, et al. How health care systems let our patients down: a systematic review into suicide deaths. Int J Qual Health Care. 2020;32(5):285-291. doi:10.1…
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psnet.ahrq.gov/issue/interventions-increase-patient-safety-long-term-care-facilities-umbrella-review
September 01, 2021 - Review
Interventions to increase patient safety in long-term care facilities-umbrella review.
Citation Text:
Świtalski J, Wnuk K, Tatara T, et al. Interventions to increase patient safety in long-term care facilities-umbrella review. Int J Environ Res Public Health. 2022;19(22):15354. do…
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psnet.ahrq.gov/issue/frequency-diagnostic-errors-neonatal-intensive-care-unit-retrospective-cohort-study
April 13, 2022 - Study
Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.
Citation Text:
Shafer GJ, Singh H, Thomas EJ, et al. Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study. J Perinatol. 2022;42(10):1312-131…
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psnet.ahrq.gov/issue/association-between-implementation-medical-team-training-program-and-surgical-morbidity
July 03, 2014 - Study
Association between implementation of a medical team training program and surgical morbidity.
Citation Text:
Young-Xu Y, Neily J, Mills PD, et al. Association between implementation of a medical team training program and surgical morbidity. Arch Surg. 2011;146(12):1368-73. doi:10.1…
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psnet.ahrq.gov/issue/explanation-and-elaboration-squire-standards-quality-improvement-reporting-excellence
November 18, 2016 - Commentary
Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature.
Citation Text:
Goodman D, Ogrinc G, Davies L, et al. Explanation and elaboration of the S…
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psnet.ahrq.gov/issue/how-safe-are-paediatric-emergency-departments-national-prospective-cohort-study
May 20, 2020 - Study
How safe are paediatric emergency departments? A national prospective cohort study.
Citation Text:
Plint AC, Newton AS, Stang A, et al. How safe are paediatric emergency departments? A national prospective cohort study. BMJ Qual Saf. 2022;31(11):806-817. doi:10.1136/bmjqs-2021-0146…
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psnet.ahrq.gov/issue/creating-framework-integrate-residency-program-and-medical-center-approaches-quality
November 11, 2020 - Commentary
Creating a framework to integrate residency program and medical center approaches to quality improvement and patient safety training
Citation Text:
Chen A, Wolpaw BJ, Vande Vusse LK, et al. Creating a framework to integrate residency program and medical center approaches to qu…
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psnet.ahrq.gov/issue/enabling-enacting-and-elaborating-factors-safety-culture-associated-patient-safety-multilevel
September 21, 2022 - Study
The enabling, enacting, and elaborating factors of safety culture associated with patient safety: a multilevel analysis.
Citation Text:
Lee SE, Dahinten VS. The enabling, enacting, and elaborating factors of safety culture associated with patient safety: a multilevel analysis. J Nu…
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psnet.ahrq.gov/issue/improving-medication-safety-paediatric-hospital-mixed-methods-evaluation-newly-implemented
August 30, 2023 - Study
Improving medication safety in a paediatric hospital: a mixed-methods evaluation of a newly implemented computerised provider order entry system.
Citation Text:
Improving medication safety in a paediatric hospital: a mixed-methods evaluation of a newly implemented computerised prov…
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psnet.ahrq.gov/issue/development-preliminary-patient-safety-classification-system-generative-ai
December 21, 2022 - Study
Development of a preliminary patient safety classification system for generative AI.
Citation Text:
Hose B-Z, Handley JL, Biro J, et al. Development of a preliminary patient safety classification system for generative AI. BMJ Qual Saf. 2025;34(2):130-132. doi:10.1136/bmjqs-2024-017…
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psnet.ahrq.gov/node/867655/psn-pdf
February 26, 2025 - Learning Health Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
Despite an observable decrease in adverse events in health care over time, rat…
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psnet.ahrq.gov/node/33870/psn-pdf
November 01, 2018 - The Comprehensivist Model of Care: A Hospitalist's View
November 1, 2018
Wachter R. The Comprehensivist Model of Care: A Hospitalist's View. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
Perspective
In this month's PSNet perspective, I interview Dr. David M…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
May 01, 2006 - Spotlight Case
Spotlight Case May 2006
Right? Left? Neither!
Source and Credits
This presentation is based on the May 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD…
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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - Handoffs and Transitions
January 22, 2014
Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/handoffs-and-transitions
Annual Perspective 2014
Despite recent efforts to promote clinical integration, the United States health care system remains highly
fragmented. From it…