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psnet.ahrq.gov/node/48013/psn-pdf
May 29, 2019 - Economic outcomes associated with safety interventions
by a pharmacist–adjudicated prior authorization consult
service.
May 29, 2019
Jacob S, Britt RB, Bryan WE, et al. Economic Outcomes Associated with Safety Interventions by a
Pharmacist-Adjudicated Prior Authorization Consult Service. J Manag Care Spec Pharm. 2…
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psnet.ahrq.gov/node/60003/psn-pdf
January 01, 2021 - Systemic causes of in-hospital intravenous medication
errors: a systematic review.
March 4, 2020
Kuitunen S, Niittynen I, Airaksinen M, et al. Systemic causes of in-hospital intravenous medication errors: a
systematic review. J Patient Saf. 2021;17(8):e1660-e1668. doi:10.1097/pts.0000000000000632.
https://psnet.ah…
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psnet.ahrq.gov/node/47975/psn-pdf
May 29, 2019 - Surgical Innovation, New Techniques and Technologies:
A Guide to Good Practice.
May 29, 2019
London, UK: Royal College of Surgeons of England; 2019.
https://psnet.ahrq.gov/issue/surgical-innovation-new-techniques-and-technologies-guide-good-practice
Introducing innovations in practice involves taking calculated ri…
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psnet.ahrq.gov/node/39119/psn-pdf
November 25, 2009 - Effect of a weight-based prescribing method within an
electronic health record on prescribing errors.
November 25, 2009
Ginzburg R, Barr WB, Harris M, et al. Effect of a weight-based prescribing method within an electronic
health record on prescribing errors. Am J Health Syst Pharm. 2009;66(22):2037-41.
doi:10.214…
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psnet.ahrq.gov/node/46046/psn-pdf
April 19, 2017 - Teaching students to administer medications safely.
April 19, 2017
Koharchik L, Flavin PM. Teaching Students to Administer Medications Safely. Am J Nurs. 2017;117(1):62-
66. doi:10.1097/01.NAJ.0000511573.73435.72.
https://psnet.ahrq.gov/issue/teaching-students-administer-medications-safely
Students are likely to m…
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psnet.ahrq.gov/node/45547/psn-pdf
October 05, 2016 - Sick children face potentially deadly danger: medication
errors.
October 5, 2016
Furfaro H. Wall Street Journal. September 25, 2016.
https://psnet.ahrq.gov/issue/sick-children-face-potentially-deadly-danger-medication-errors
Medication errors in pediatric care are common in the hospital and at home. This newspaper…
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psnet.ahrq.gov/node/35749/psn-pdf
May 09, 2014 - Chemotherapy dose limits set by users of a computer
order entry system.
May 9, 2014
DuBeshter B; Griggs J; Angel C; Loughner J.
https://psnet.ahrq.gov/issue/chemotherapy-dose-limits-set-users-computer-order-entry-system
To avoid excessive dosing of chemotherapeutic agents, standardized dose limits must be agreed u…
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psnet.ahrq.gov/node/36895/psn-pdf
March 10, 2011 - A systematic review of the performance characteristics of
clinical event monitor signals used to detect adverse drug
events in the hospital setting.
March 10, 2011
Handler S, Altman RL, Perera S, et al. A systematic review of the performance characteristics of clinical
event monitor signals used to detect adverse …
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psnet.ahrq.gov/node/44082/psn-pdf
April 22, 2015 - Impact of including readmissions for qualifying events in
the Patient Safety Indicators.
April 22, 2015
Davies SM, Saynina O, Baker LC, et al. Impact of including readmissions for qualifying events in the patient
safety indicators. Am J Med Qual. 2015;30(2):114-8. doi:10.1177/1062860613518341.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/860724/psn-pdf
January 17, 2024 - Retrospective cohort study of wrong-patient imaging
order errors: how many reach the patient?
January 17, 2024
Kneifati-Hayek JZ, Geist E, Applebaum JR, et al. Retrospective cohort study of wrong-patient imaging
order errors: how many reach the patient? BMJ Qual Saf. 2024;33(2):132-135. doi:10.1136/bmjqs-2023-
016…
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psnet.ahrq.gov/node/867230/psn-pdf
December 04, 2024 - Adaption of a trigger tool to identify harmful incidents, no
harm incidents, and near misses in prehospital
emergency care of children.
December 4, 2024
Packendorff N, Magnusson C, Axelsson C, et al. Adaption of a trigger tool to identify harmful incidents, no
harm incidents, and near misses in prehospital emergen…
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psnet.ahrq.gov/node/60726/psn-pdf
January 01, 2021 - User-testing guidelines to improve the safety of
intravenous medicines administration: a randomised in
situ simulation study.
July 29, 2020
Jones MD, McGrogan A, Raynor DK, et al. User-testing guidelines to improve the safety of intravenous
medicines administration: a randomised in situ simulation study. BMJ Qual …
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psnet.ahrq.gov/node/74151/psn-pdf
January 01, 2022 - Nursing interventions to reduce medication errors in
paediatrics and neonates: systematic review and meta-
analysis.
December 8, 2021
Marufu TC, Bower R, Hendron E, et al. Nursing interventions to reduce medication errors in paediatrics and
neonates: systematic review and meta-analysis. J Pediatr Nurs. 2022;62:e13…
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psnet.ahrq.gov/node/848366/psn-pdf
May 03, 2023 - The effect of documenting patient weight in kilograms on
pediatric medication dosing errors in emergency medical
services.
May 3, 2023
Ward CE, Taylor M, Keeney C, et al. The effect of documenting patient weight in kilograms on pediatric
medication dosing errors in emergency medical services. Prehosp Emerg Care. 2…
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psnet.ahrq.gov/node/43047/psn-pdf
August 02, 2015 - Hospital readmission after noncardiac surgery: the role of
major complications.
August 2, 2015
Glance LG, Kellermann AL, Osler T, et al. Hospital readmission after noncardiac surgery: the role of major
complications. JAMA Surg. 2014;149(5):439-45.
https://psnet.ahrq.gov/issue/hospital-readmission-after-noncardiac-…
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psnet.ahrq.gov/node/34786/psn-pdf
March 28, 2005 - Errors in drug computations during newborn intensive
care.
March 28, 2005
Perlstein PH, Callison C, White M, et al. Errors in Drug Computations During Newborn Intensive Care. Arch
Pediatr Adolesc Med. 1979;133(4):376-379. doi:10.1001/archpedi.1979.02130040030006.
https://psnet.ahrq.gov/issue/errors-drug-computatio…
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psnet.ahrq.gov/node/49394/psn-pdf
April 01, 2003 - Premature or Overdue?
April 1, 2003
Thomas J, Hannah M. Premature or Overdue? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/premature-or-overdue
The Case
A 32-year-old woman, gravida 3, para 1, presented for prenatal care at 24 weeks. Her past medical history
was unremarkable, and results of her prenatal …
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psnet.ahrq.gov/issue/transitions-care-toc-portal
March 07, 2018 - Multi-use Website
Transitions of Care (TOC) Portal.
Save
Save to your library
Print
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February 27, 2013
This Web site provides resources for clinicians and patien…
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psnet.ahrq.gov/node/47130/psn-pdf
October 10, 2018 - Are clinical instructors preventing or provoking adverse
events involving students: a contemporary issue.
October 10, 2018
Christensen L. Are clinical instructors preventing or provoking adverse events involving students: A
contemporary issue. Nurse Educ Today. 2018;70:121-123. doi:10.1016/j.nedt.2018.08.024.
http…
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psnet.ahrq.gov/node/46304/psn-pdf
November 01, 2017 - Comparative performance of pediatric weight estimation
techniques: a human factor errors analysis.
November 1, 2017
Abdel-Rahman SM, Jacobsen R, Watts JL, et al. Comparative performance of pediatric weight estimation
techniques: a human factor errors analysis. Pediatr Emerg Care. 2015;33(8):548-552.
doi:10.1097/pe…