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psnet.ahrq.gov/node/60828/psn-pdf
August 19, 2020 - When COVID-19 hit, many elderly were left to die.
August 19, 2020
Stevis-Gridneff M, Apuzzo M, Pronczuk M. When COVID-19 hit, many elderly were left to die. New York
Times. 2020;August 8.
https://psnet.ahrq.gov/issue/when-covid-19-hit-many-elderly-were-left-die
Residential care facilities have been challenged by C…
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psnet.ahrq.gov/node/49790/psn-pdf
April 01, 2017 - record, separately if possible but together if not, and should not be removed from the record without
consideration
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psnet.ahrq.gov/node/39723/psn-pdf
February 01, 2011 - Barriers and facilitators to chemotherapy patients'
engagement in medical error prevention.
February 1, 2011
Schwappach DLB, Wernli M. Barriers and facilitators to chemotherapy patients' engagement in medical
error prevention. Ann Oncol. 2011;22(2):424-30. doi:10.1093/annonc/mdq346.
https://psnet.ahrq.gov/issue/ba…
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psnet.ahrq.gov/node/853622/psn-pdf
January 01, 2024 - Enhancing patient safety: a national standard for cyber
resiliency in healthcare.
September 20, 2023
Samuelson-Kiraly C, Mitchell JI, Kingston D, et al. Enhancing patient safety: A national standard for cyber
resiliency in healthcare. Healthc Manage Forum. 2024;37(1):9-12. doi:10.1177/08404704231196138.
https://ps…
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psnet.ahrq.gov/node/857452/psn-pdf
December 06, 2023 - Improving patient safety governance and systems
through learning from successes and failures: qualitative
surveys and interviews with international experts.
December 6, 2023
Hibbert PD, Stewart S, Wiles LK, et al. Improving patient safety governance and systems through learning
from successes and failures: qualita…
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psnet.ahrq.gov/node/33602/psn-pdf
March 15, 2025 - Individual Clinician Performance Issues
March 15, 2025
Individual Clinician Performance Issues. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/individual-clinician-performance-issues
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current res…
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psnet.ahrq.gov/node/33565/psn-pdf
September 01, 2024 - Healthcare-associated Infections
June 15, 2024
Healthcare - Associated Infections. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/health-care-associated-infections
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice …
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psnet.ahrq.gov/node/35188/psn-pdf
August 16, 2016 - The Handbook of Patient Safety Compliance: A Practical
Guide for Health Care Organizations.
August 16, 2016
Rozovsky FA, Woods JR. San Francisco, CA: Jossey-Bass; 2005. ISBN 9780787965105.
https://psnet.ahrq.gov/issue/handbook-patient-safety-compliance-practical-guide-health-care-organizations
This well-referenced…
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psnet.ahrq.gov/node/41500/psn-pdf
May 10, 2013 - First year nursing students' viewpoints about
compromised clinical safety.
May 10, 2013
Killam LA, Mossey S, Montgomery P, et al. First year nursing students' viewpoints about compromised
clinical safety. Nurse Educ Today. 2013;33(5):475-80. doi:10.1016/j.nedt.2012.05.010.
https://psnet.ahrq.gov/issue/first-year-n…
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psnet.ahrq.gov/node/39783/psn-pdf
August 25, 2010 - Ethics, oversight and quality improvement initiatives.
August 25, 2010
Taylor HA, Pronovost PJ, Sugarman J. Ethics, oversight and quality improvement initiatives. Quality and
Safety in Health Care. 2010;19(4). doi:10.1136/qshc.2009.038034.
https://psnet.ahrq.gov/issue/ethics-oversight-and-quality-improvement-initia…
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psnet.ahrq.gov/node/41416/psn-pdf
May 23, 2012 - Checking anaesthetic equipment 2012: Association of
Anaesthetists of Great Britain and Ireland.
May 23, 2012
Anderson E, Bythell V, Gemmell L, et al. Checking Anaesthetic Equipment 2012. Anaesthesia. 2012;67(6).
doi:10.1111/j.1365-2044.2012.07163.x.
https://psnet.ahrq.gov/issue/checking-anaesthetic-equipment-2012-…
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psnet.ahrq.gov/node/837856/psn-pdf
August 17, 2022 - Nurse well-being: a concept analysis.
August 17, 2022
Patrician PA, Bakerjian D, Billings R, et al. Nurse well-being: a concept analysis. Nurs Outlook.
2022;70(4):639-650. doi:10.1016/j.outlook.2022.03.014.
https://psnet.ahrq.gov/issue/nurse-well-being-concept-analysis
Clinician well-being has important implicatio…
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psnet.ahrq.gov/node/838644/psn-pdf
October 19, 2022 - Golden State Medical Supply, Inc. Issues a Voluntary
Nationwide Recall of Atenolol 25 mg Tablets and
Clopidogrel 75 mg Tablets Due to a Label Mix-up.
October 19, 2022
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 29, 2022.
https://psnet.ahrq.gov/issue/golden-state-medical-sup…
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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/866159/psn-pdf
June 19, 2024 - Stakeholder perspectives on contributors to delayed and
inaccurate diagnosis of cardiovascular disease and their
implications for digital health technologies: a UK-based
qualitative study.
June 19, 2024
Abdullayev K, Gorvett O, Sochiera A, et al. Stakeholder perspectives on contributors to delayed and
inaccurate …
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psnet.ahrq.gov/node/43239/psn-pdf
June 11, 2014 - A cycle of redemption in a medical error disclosure and
apology program.
June 11, 2014
Carmack HJ. A Cycle of Redemption in a Medical Error Disclosure and Apology Program. Qual Health Res.
2014;24(6):860-869.
https://psnet.ahrq.gov/issue/cycle-redemption-medical-error-disclosure-and-apology-program
Clinicians who…
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psnet.ahrq.gov/node/40912/psn-pdf
March 02, 2012 - Enhancing patient safety with intelligent intravenous
infusion devices: experience in a specialty cardiac
hospital.
March 2, 2012
Wood JL, Burnette JS. Enhancing patient safety with intelligent intravenous infusion devices: Experience in
a specialty cardiac hospital. Heart & Lung. 2011;41(2). doi:10.1016/j.hrtlng.…
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psnet.ahrq.gov/node/34798/psn-pdf
June 23, 2015 - Costs of medical injuries in Utah and Colorado.
June 23, 2015
Thomas EJ; Studdert DM; Newhouse JP; Zbar BI; Howard KM; Williams EJ; Brennan TA
https://psnet.ahrq.gov/issue/costs-medical-injuries-utah-and-colorado
This study analyzed more than 450 adverse events from a representative hospital sample in order to
est…
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psnet.ahrq.gov/node/44182/psn-pdf
November 03, 2015 - FDA cautions about dose confusion and medication
errors for antibacterial drug Zerbaxa (ceftolozane and
tazobactam).
November 3, 2015
Food and Drug Administration; FDA.
https://psnet.ahrq.gov/issue/fda-cautions-about-dose-confusion-and-medication-errors-antibacterial-drug-
zerbaxa
Dosing information on drug labe…
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psnet.ahrq.gov/node/61096/psn-pdf
November 04, 2020 - Wrong drug and wrong dose dispensing errors identified
in pharmacist professional liability claims.
November 4, 2020
Reiner G, Pierce SL, Flynn J. J Am Pharm Assoc (2003). 2020;60(5):e50-e56.
https://psnet.ahrq.gov/issue/wrong-drug-and-wrong-dose-dispensing-errors-identified-pharmacist-
professional-liability
Des…