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psnet.ahrq.gov/issue/risks-implementation-and-use-smart-pumps-pediatric-intensive-care-unit-application-failure
March 09, 2022 - Study
Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure mode and effects analysis.
Citation Text:
Manrique-Rodríguez S, Sánchez-Galindo AC, López-Herce J, et al. Risks in the implementation and use of smart pumps in a pediat…
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psnet.ahrq.gov/issue/application-strong-matrix-management-and-pdca-cycle-management-severe-covid-19-patients
March 24, 2019 - Commentary
The application of strong matrix management and PDCA cycle in the management of severe COVID-19 patients.
Citation Text:
Li Y, Wang H, Jiao J. The application of strong matrix management and PDCA cycle in the management of severe COVID-19 patients. Crit Care. 2020;24(1):157. d…
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psnet.ahrq.gov/node/837346/psn-pdf
June 08, 2022 - Decontamination of Surgical Instruments.
June 8, 2022
Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022.
https://psnet.ahrq.gov/issue/decontamination-surgical-instruments
Surgical equipment sterilization can be hampered by equipment design, production pressures, process
complexity and policy mi…
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psnet.ahrq.gov/node/50784/psn-pdf
January 08, 2020 - Improving Quality of Care and Patient Outcomes During
Care Transitions (R01).
January 8, 2020
Rockville, MD: Agency for Healthcare Research and Quality; December 6, 2019. PA-20-068.
https://psnet.ahrq.gov/issue/improving-quality-care-and-patient-outcomes-during-care-transitions-r01
Communication during patient tra…
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psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
February 20, 2019 - Clinically applicable deep learning for diagnosis and referral in retinal disease.
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psnet.ahrq.gov/issue/call-application-patient-safety-culture-medical-humanitarian-action-literature-review
February 10, 2021 - Review
A call for the application of patient safety culture in medical humanitarian action: a literature review.
Citation Text:
Biquet J-M, Schopper D, Sprumont D, et al. A call for the application of patient safety culture in medical humanitarian action: a literature review. J Patient S…
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psnet.ahrq.gov/primer/triggers-and-trigger-tools
September 15, 2024 - The GTT includes 53 different triggers, some applicable to all patients and some inappropriate for certain
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psnet.ahrq.gov/node/47265/psn-pdf
February 22, 2019 - Introduction of a mobile adverse event reporting system
is associated with participation in adverse event
reporting.
February 22, 2019
Rubin DS, Pesyna C, Jakubczyk S, et al. Introduction of a Mobile Adverse Event Reporting System Is
Associated With Participation in Adverse Event Reporting. Am J Med Qual. 2019;34(…
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psnet.ahrq.gov/node/49752/psn-pdf
January 01, 2016 - Inadvertent Use of More Potent Acid Leads to Burn
January 1, 2016
Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
The Case
A 31-year-old woman came to the clinic for a routine well-woman evaluation. She…
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psnet.ahrq.gov/issue/application-emergency-preparedness-principles-pharmacy-departments-approach-black-swan-event
July 22, 2020 - Commentary
Application of emergency preparedness principles to a pharmacy department’s approach to a “black swan” event: the COVID-19 pandemic.
Citation Text:
Waldron KM, Schenkat DH, Rao KV, et al. Application of emergency preparedness principles to a pharmacy department’s approach to a…
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psnet.ahrq.gov/issue/applicability-healthcare-failure-mode-and-effects-analysis-healthcare-epidemiology-evaluation
October 19, 2022 - Study
Applicability of Healthcare Failure Mode and Effects Analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments.
Citation Text:
Weinstein RA, Linkin DR, Sausman C, et al. Applicability of Healthcare Failure Mode and Effects Analysis to Heal…
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psnet.ahrq.gov/issue/application-trigger-tools-detecting-adverse-drug-events-older-people-systematic-review-and
June 15, 2022 - Review
Application of trigger tools for detecting adverse drug events in older people: a systematic review and meta-analysis.
Citation Text:
Schiavo G, Forgerini M, Varallo FR, et al. Application of trigger tools for detecting adverse drug events in older people: a systematic review and …
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psnet.ahrq.gov/issue/application-human-factors-methods-ensure-appropriate-infant-identification-and-abduction
April 27, 2022 - Commentary
Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting.
Citation Text:
Webster KLW, Stikes R, Bunnell L, et al. Application of human factors methods to ensure appropriate infant identification and a…
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psnet.ahrq.gov/node/867445/psn-pdf
January 08, 2025 - Using human factors methods to mitigate bias in artificial
intelligence-based clinical decision support.
January 8, 2025
Militello LG, Diiulio J, Wilson DL, et al. Using human factors methods to mitigate bias in artificial
intelligence-based clinical decision support. J Am Med Inform Assoc. 2025;32(2):398-403.
doi…
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psnet.ahrq.gov/node/862997/psn-pdf
February 21, 2024 - What kinds of insights do Safety-I and Safety-II
approaches provide? A critical reflection on the use of
SHERPA and FRAM in healthcare.
February 21, 2024
Sujan M, Lounsbury O, Pickup L, et al. What kinds of insights do Safety-I and Safety-II approaches
provide? A critical reflection on the use of SHERPA and FRAM i…
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psnet.ahrq.gov/issue/engaging-patient-and-family-surgical-safety-process-utilizing-safestart
October 19, 2022 - Study
Engaging the patient and family in the surgical safety process utilizing SafeStart.
Citation Text:
Elger BM, Esparaz JR, Nierstedt RT, et al. Engaging the patient and family in the surgical safety process utilizing. J Pediatr Surg. 2020;55(4). doi:10.1016/j.jpedsurg.2019.06.012.
…
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psnet.ahrq.gov/issue/validation-mobile-app-reducing-errors-administration-medications-emergency
September 23, 2020 - Study
Validation of a mobile app for reducing errors of administration of medications in an emergency.
Citation Text:
Baumann D, Dibbern N, Sehner S, et al. Validation of a mobile app for reducing errors of administration of medications in an emergency. J Clin Monit Comput. . 2019;33(3):…
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psnet.ahrq.gov/issue/mistaken-identity-skin-cleansing-solution-leading-extensive-chemical-burns-extremely-preterm
October 19, 2022 - Commentary
Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infant.
Citation Text:
Mannan K, Chow P, Lissauer T, et al. Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infan…
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psnet.ahrq.gov/issue/grand-rounds-methodology-key-considerations-implementing-machine-learning-solutions-quality
July 26, 2023 - Commentary
Grand rounds in methodology: key considerations for implementing machine learning solutions in quality improvement initiatives.
Citation Text:
Verma AA, Trbovich PL, Mamdani MM, et al. Grand rounds in methodology: key considerations for implementing machine learning solutions …
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psnet.ahrq.gov/node/47724/psn-pdf
March 20, 2019 - Understanding patient safety and quality outcome data.
March 20, 2019
Easter K, Tamburri LM. Understanding Patient Safety and Quality Outcome Data. Crit Care Nurse.
2018;38(6):58-66. doi:10.4037/ccn2018979.
https://psnet.ahrq.gov/issue/understanding-patient-safety-and-quality-outcome-data
Public reporting of safet…