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  1. Direct reporting of laboratory test results to patients by mail to enhance patient safety. | PSNet

    psnet.ahrq.gov/issue/direct-reporting-laboratory-test-results-patients-mail-enhance-patient-safety
    February 15, 2011 - Study Direct reporting of laboratory test results to patients by mail to enhance patient safety. Citation Text: Sung S, Forman-Hoffman VL, Wilson MC, et al. Direct reporting of laboratory test results to patients by mail to enhance patient safety. J Gen Intern Med. 2006;21(10):1075-8. …

  2. Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice. | PSNet

    psnet.ahrq.gov/issue/laboratory-test-ordering-and-results-management-systems-qualitative-study-safety-risks
    March 16, 2016 - Study Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice. Citation Text: Bowie P, Halley L, McKay J. Laboratory test ordering and results management systems: a qualitative study of safety risks id…

  3. Detection of adverse drug events using an electronic trigger tool. | PSNet

    psnet.ahrq.gov/issue/detection-adverse-drug-events-using-electronic-trigger-tool
    October 02, 2013 - Study Detection of adverse drug events using an electronic trigger tool. Citation Text: Lim D, Melucci J, Rizer MK, et al. Detection of adverse drug events using an electronic trigger tool. Am J Health Syst Pharm. 2016;73(17 Suppl 4):S112-20. doi:10.2146/ajhp150481. Copy Citation F…

  4. Patient safety incidents in endoscopy: a human factors analysis of non-procedural significant harm incidents from the National Reporting and Learning System (NRLS). | PSNet

    psnet.ahrq.gov/issue/patient-safety-incidents-endoscopy-human-factors-analysis-non-procedural-significant-harm
    January 29, 2020 - Study Patient safety incidents in endoscopy: a human factors analysis of non-procedural significant harm incidents from the National Reporting and Learning System (NRLS). Citation Text: Ravindran S, Matharoo M, Rutter MD, et al. Patient safety incidents in endoscopy: a human factors anal…

  5. Evaluation of a Web-based education program on reducing medication dosing error: a multicenter, randomized controlled trial. | PSNet

    psnet.ahrq.gov/issue/evaluation-web-based-education-program-reducing-medication-dosing-error-multicenter
    May 18, 2022 - Study Evaluation of a Web-based education program on reducing medication dosing error: a multicenter, randomized controlled trial. Citation Text: Frush K, Hohenhaus S, Luo X, et al. Evaluation of a Web-based education program on reducing medication dosing error: a multicenter, randomiz…

  6. Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the United States. | PSNet

    psnet.ahrq.gov/issue/association-clinical-knowledge-support-system-improved-patient-safety-reduced-complications
    October 19, 2022 - Study Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the United States. Citation Text: Bonis PA, Pickens GT, Rind DM, et al. Association of a clini…

  7. Five system barriers to achieving ultrasafe health care. | PSNet

    psnet.ahrq.gov/issue/five-system-barriers-achieving-ultrasafe-health-care
    September 29, 2017 - Commentary Classic Five system barriers to achieving ultrasafe health care. Citation Text: Amalberti R, Auroy Y, Berwick D, et al. Five system barriers to achieving ultrasafe health care. Ann Intern Med. 2005;142(9):756-64. Copy Citation Format: …

  8. Reducing ambulatory central line-associated bloodstream infections: a family-centered approach. | PSNet

    psnet.ahrq.gov/issue/reducing-ambulatory-central-line-associated-bloodstream-infections-family-centered-approach
    February 15, 2023 - Study Reducing ambulatory central line-associated bloodstream infections: a family-centered approach. Citation Text: Wong CI, Ilowite M, Yan A, et al. Reducing ambulatory central line‐associated bloodstream infections: a family‐centered approach. Pediatr Blood Cancer. 2024;71(8):e31064. …

  9. What is the scale of prescribing errors committed by junior doctors? A systematic review. | PSNet

    psnet.ahrq.gov/issue/what-scale-prescribing-errors-committed-junior-doctors-systematic-review
    January 30, 2013 - Review What is the scale of prescribing errors committed by junior doctors? A systematic review. Citation Text: Ross S, Bond C, Rothnie H, et al. What is the scale of prescribing errors committed by junior doctors? A systematic review. Br J Clin Pharmacol. 2009;67(6):629-40. doi:10.111…

  10. Medication order errors at hospital admission among children with medical complexity | PSNet

    psnet.ahrq.gov/issue/medication-order-errors-hospital-admission-among-children-medical-complexity
    July 20, 2022 - Study Medication order errors at hospital admission among children with medical complexity Citation Text: Blaine K, Wright J, Pinkham A, et al. Medication Order Errors at Hospital Admission Among Children With Medical Complexity. J Patient Saf. 2022;18(1):e156-e162. doi:10.1097/pts.00000…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36534/psn-pdf
    March 09, 2009 - Standardizing hand-off processes. March 9, 2009 Gregory BSC. Standardizing hand-off processes. AORN J. 2006;84(6):1059-61. https://psnet.ahrq.gov/issue/standardizing-hand-processes The author suggests ways to improve hand-off communications and provides an assessment form to assist staff in detecting weaknesses in…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38320/psn-pdf
    July 28, 2013 - State of Healthcare 2008. July 28, 2013 Healthcare Commission. London, England: Commission for Healthcare Audit and Inspection; 2008. ISBN: 9780102958362. https://psnet.ahrq.gov/issue/state-healthcare-2008 This report assesses care in the United Kingdom, provides data on a variety of issues related to safety, and …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36584/psn-pdf
    January 12, 2011 - Will my patient fall? January 12, 2011 Ganz DA, Bao Y, Shekelle PG, et al. Will my patient fall? JAMA. 2007;297(1):77-86. https://psnet.ahrq.gov/issue/will-my-patient-fall The authors assessed the literature to determine risk factors for falls that can be identified to help prevent such injuries. https://psnet.ah…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36336/psn-pdf
    October 26, 2010 - Interprofessional Approaches to Patient Safety. October 26, 2010 J Interprof Care. 2006;20(5):461-563. https://psnet.ahrq.gov/issue/interprofessional-approaches-patient-safety This issue includes articles that explore successful multidisciplinary efforts to improve patient safety, including medication risk assessm…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857060/psn-pdf
    November 27, 2023 - The Role of Undergraduate Nursing Education in Patient Safety November 27, 2023 Stanley J, Gale B, Mossburg S. The Role of Undergraduate Nursing Education in Patient Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety Introduction Nurses are a li…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49551/psn-pdf
    December 01, 2007 - Too Hot For Comfort December 1, 2007 Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/too-hot-comfort The Case A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV antibiotics via a peripheral line in the left antec…

  17. The Hidden Harms of Hand Sanitizer | PSNet

    psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
    March 04, 2020 - The Hidden Harms of Hand Sanitizer Citation Text: Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

  18. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
    May 01, 2012 - Spotlight Case July 2008 Spotlight Case The Perils of Cross Coverage * * Source and Credits This presentation is based on the May 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38367/psn-pdf
    May 24, 2015 - Pathways for Patient Safety. May 24, 2015 Chicago, IL: Health Research and Educational Trust, Institute for Safe Medication Practices, Medical Group Management Association; 2009. https://psnet.ahrq.gov/issue/pathways-patient-safety This trio of modules provides ambulatory medical practices with tools to develop te…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73128/psn-pdf
    July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. April 7, 2021 https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications- and-enhances Summary The Hospital at Homesm program provides hospital-level care…
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