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psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - January 2, 2017
Programmable infusion pumps in ICUs: an analysis of corresponding adverse … drug events. … February 22, 2011
Costs of intravenous adverse drug events in academic and nonacademic
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psnet.ahrq.gov/issue/tackling-tube-misconnections
August 17, 2016 - Newspaper/Magazine Article
Tackling tube misconnections.
Citation Text:
Tackling tube misconnections. Landro L.
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psnet.ahrq.gov/issue/fair-and-reliable-medical-justice-act
March 06, 2005 - Legislation/Case Law
Fair and Reliable Medical Justice Act.
Citation Text:
Fair and Reliable Medical Justice Act. Enzi M; Baucus M.
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psnet.ahrq.gov/node/49517/psn-pdf
August 01, 2006 - Miscalculated Risk
August 1, 2006
Strassels SA. Miscalculated Risk. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/miscalculated-risk
The Case
A healthy 36-year-old man was admitted to a teaching hospital for acute low back strain after lifting his 2-
week-old infant. He received Vicodin (hydrocodone and a…
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psnet.ahrq.gov/primer/long-term-care-and-patient-safety
February 24, 2022 - Adverse drug events were the most common type of adverse event in the 2014 OIG study as well as in other
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psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
September 01, 2004 - Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285:2114-2120.
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psnet.ahrq.gov/web-mm/2-week-itch
June 16, 2019 - November 16, 2022
Completeness of serious adverse drug event reports received by the
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psnet.ahrq.gov/issue/expanding-role-antimicrobial-stewardship-programs-hospitals-united-states-lessons-learned
March 04, 2015 - Study
The expanding role of antimicrobial stewardship programs in hospitals in the United States: lessons learned from a multisite qualitative study.
Citation Text:
Kapadia SN, Abramson EL, Carter EJ, et al. The Expanding Role of Antimicrobial Stewardship Programs in Hospitals in the Uni…
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psnet.ahrq.gov/issue/design-and-implementation-infection-prevention-program-risk-management-managing-high-level
December 18, 2014 - Study
Design and implementation of the infection prevention program into risk management: managing high level disinfection and sterilization in the outpatient setting.
Citation Text:
Sweet W, Snyder D, Raymond M. Design and implementation of the infection prevention program into risk man…
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psnet.ahrq.gov/issue/leapfrog-safety-grades-california-hospitals-data-analysis
November 16, 2022 - Study
Leapfrog safety grades in California hospitals: a data analysis.
Citation Text:
Razick D, Amani N, Ali L, et al. Leapfrog safety grades in California hospitals: a data analysis. Am J Med Qual. 2024;39(5):251-255. doi:10.1097/jmq.0000000000000200.
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psnet.ahrq.gov/issue/effect-residential-care-pharmacist-medication-administration-practices-aged-care-controlled
August 31, 2016 - Study
The effect of a residential care pharmacist on medication administration practices in aged care: a controlled trial.
Citation Text:
McDerby N, Kosari S, Bail K, et al. The effect of a residential care pharmacist on medication administration practices in aged care: A controlled tria…
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psnet.ahrq.gov/issue/increasing-patient-safety-neonates-handoff-communication-during-delivery-call
March 19, 2019 - Commentary
Increasing patient safety with neonates via handoff communication during delivery: a call for interprofessional health care team training across GME and CME.
Citation Text:
Vanderbilt AA, Pappada SM, Stein H, et al. Increasing patient safety with neonates via handoff communica…
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psnet.ahrq.gov/issue/war-two-fronts-cancer-care-time-covid-19
March 12, 2025 - Commentary
A war on two fronts: cancer care in the time of COVID-19.
Citation Text:
Kutikov A, Weinberg DS, Edelman MJ, et al. A war on two fronts: cancer care in the time of COVID-19. Ann Intern Med. 2020;172(11):756-758. doi:10.7326/m20-1133.
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psnet.ahrq.gov/issue/understanding-test-results-follow-ambulatory-setting-analysis-multiple-perspectives
May 20, 2019 - Study
Understanding test results follow-up in the ambulatory setting: analysis of multiple perspectives.
Citation Text:
Ai A, Desai S, Shellman A, et al. Understanding Test Results Follow-Up in the Ambulatory Setting: Analysis of Multiple Perspectives. Jt Comm J Qual Patient Saf. 2018;44…
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psnet.ahrq.gov/issue/information-technology-interventions-improve-medication-safety-primary-care-systematic-review
July 29, 2020 - Review
Information technology interventions to improve medication safety in primary care: a systematic review.
Citation Text:
Lainer M, Mann E, Sönnichsen A. Information technology interventions to improve medication safety in primary care: a systematic review. Int J Qual Health Care. 20…
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psnet.ahrq.gov/issue/changes-default-alarm-settings-and-standard-service-are-insufficient-improve-alarm-fatigue
May 29, 2019 - Study
Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: a pilot project.
Citation Text:
Sowan AK, Gomez TM, Tarriela AF, et al. Changes in Default Alarm Settings and Standard In-Service are Insufficient to Impro…
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psnet.ahrq.gov/issue/impact-pharmacist-medication-reconciliation-patient-admission-veterans-affairs-medical-center
July 22, 2020 - Study
Impact of a pharmacist on medication reconciliation on patient admission to a Veterans Affairs Medical Center.
Citation Text:
Strunk LB, Matson AW, Steinke DT. Impact of a Pharmacist on Medication Reconciliation on Patient Admission to a Veterans Affairs Medical Center. Hosp Pharm.…
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psnet.ahrq.gov/issue/adapting-cognitive-task-analysis-investigate-clinical-decision-making-and-medication-safety
March 10, 2021 - Study
Adapting cognitive task analysis to investigate clinical decision making and medication safety incidents.
Citation Text:
Russ AL, Militello LG, Glassman PA, et al. Adapting Cognitive Task Analysis to Investigate Clinical Decision Making and Medication Safety Incidents. J Patient Sa…
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psnet.ahrq.gov/issue/functional-decline-associated-polypharmacy-and-potentially-inappropriate-medications
June 13, 2018 - Study
Functional decline associated with polypharmacy and potentially inappropriate medications in community-dwelling older adults with dementia.
Citation Text:
Lau DT, Mercaldo ND, Shega JW, et al. Functional decline associated with polypharmacy and potentially inappropriate medicatio…
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psnet.ahrq.gov/issue/electronic-tools-support-medication-reconciliation-systematic-review
August 18, 2021 - Review
Electronic tools to support medication reconciliation—a systematic review.
Citation Text:
Marien S, Krug B, Spinewine A. Electronic tools to support medication reconciliation: a systematic review. J Am Med Inform Assoc. 2017;24(1):227-240. doi:10.1093/jamia/ocw068.
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