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  1. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
    January 01, 2020 - Take-Home Points (4) 41 • Closed loop communication, developing shared goals, and situational awareness
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39477/psn-pdf
    April 28, 2010 - Effects of an adverse-drug-event alert system on cost and quality outcomes in community hospitals. April 28, 2010 Piontek F, Kohli R, Conlon P, et al. Effects of an adverse-drug-event alert system on cost and quality outcomes in community hospitals. Am J Health Syst Pharm. 2010;67(8):613-20. doi:10.2146/ajhp090056.…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44164/psn-pdf
    November 03, 2015 - Use of nondisclosure agreements in medical malpractice settlements by a large academic health care system. November 3, 2015 Sage WM, Jablonski JS, Thomas EJ. Use of Nondisclosure Agreements in Medical Malpractice Settlements by a Large Academic Health Care System. JAMA Intern Med. 2015;175(7):1130-1135. doi:10.100…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866908/psn-pdf
    October 09, 2024 - Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors. October 9, 2024 Taylor MA, Yonash RA. Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors. Patient Safety. 2024;6(1):1-11. doi:10.33940/001c.117084. https://psnet…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45802/psn-pdf
    December 12, 2018 - Intravenous smart pump drug library compliance: a descriptive study of 44 hospitals. December 12, 2018 Giuliano KK, Su W-T, Degnan DD, et al. Intravenous Smart Pump Drug Library Compliance: A Descriptive Study of 44 Hospitals. J Patient Saf. 2018;14(4):e76-e82. doi:10.1097/PTS.0000000000000383. https://psnet.ahrq.…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37271/psn-pdf
    December 19, 2011 - Is hospital patient care becoming safer? A conversation with Lucian Leape. December 19, 2011 Leape L. Is hospital patient care becoming safer? A conversation with Lucian Leape. Interview by Peter I. Buerhaus. Health Aff (Millwood). 2007;26(6):w687-96. https://psnet.ahrq.gov/issue/hospital-patient-care-becoming-saf…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39598/psn-pdf
    September 20, 2011 - A July spike in fatal medication errors: a possible effect of new medical residents. September 20, 2011 Phillips DP, Barker GEC. A July spike in fatal medication errors: a possible effect of new medical residents. J Gen Intern Med. 2010;25(8):774-9. doi:10.1007/s11606-010-1356-3. https://psnet.ahrq.gov/issue/july-…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39122/psn-pdf
    January 03, 2017 - Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy. January 3, 2017 Kliger J, Blegen MA, Gootee D, et al. Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy. Jt Comm J Qual Patient Saf.…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42802/psn-pdf
    January 07, 2015 - Patient engagement in the inpatient setting: a systematic review. January 7, 2015 Prey JE, Woollen J, Wilcox L, et al. Patient engagement in the inpatient setting: a systematic review. J Am Med Inform Assoc. 2014;21(4):742-750. doi:10.1136/amiajnl-2013-002141. https://psnet.ahrq.gov/issue/patient-engagement-inpati…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867599/psn-pdf
    January 22, 2025 - Assessing patient work system factors for medication management during transition of care among older adults: an observational study. January 22, 2025 Xiao Y, Hsu Y-J, Hannum SM, et al. Assessing patient work system factors for medication management during transition of care among older adults: an observational st…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867442/psn-pdf
    January 08, 2025 - Moving towards a core measures set for patient safety in perioperative care: an e-Delphi consensus study. January 8, 2025 Dinis-Teixeira JP, Nunes AB, Leite A, et al. Moving towards a core measures set for patient safety in perioperative care: an e-Delphi consensus study. PLoS ONE. 2024;19(10):e0311896. doi:10.137…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867606/psn-pdf
    February 10, 2025 - AHRQ PSNet Annual Webinar: Evidence on Advancing Rapid Response Systems and Opioid Stewardship. January 22, 2025 Agency for Healthcare Quality and Research. AHRQ PSNet Annual Webinar: Evidence on Advancing Rapid Response Systems and Opioid Stewardship. February 10, 2025, 1:00pm-2:00pm (eastern). https://psnet.ahrq…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840139/psn-pdf
    November 16, 2022 - CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. November 16, 2022 Dowell D, Ragan KR, Jones CM, et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep. 2022;71(3):1-95. doi:10.15585/mmwr.rr7103a1. https://psnet.ahrq.gov…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39525/psn-pdf
    March 13, 2019 - Effect of bar-code technology on the safety of medication administration. March 13, 2019 Poon EG, Keohane C, Yoon CS, et al. Effect of bar-code technology on the safety of medication administration. New Engl J Med. 2010;362(18):1698-1707. doi:10.1056/NEJMsa0907115. https://psnet.ahrq.gov/issue/effect-bar-code-tech…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36886/psn-pdf
    May 27, 2011 - The extent and importance of unintended consequences related to computerized provider order entry. May 27, 2011 Ash JS, Sittig DF, Poon EG, et al. The extent and importance of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2007;14(4):415-23. https://psnet.ahrq.gov/issu…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44965/psn-pdf
    February 15, 2017 - Identification and Prioritization of Health IT Patient Safety Measures. February 15, 2017 Washington, DC: National Quality Forum; February 2016. https://psnet.ahrq.gov/issue/identification-and-prioritization-health-it-patient-safety-measures Health information technology (IT) has transformed health care and improv…
  17. psnet.ahrq.gov/issue/patient-safety-group
    March 27, 2024 - Multi-use Website The Patient Safety Group. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL August 9, 2006 Development of The Patient Safety Group was motivated by the death of…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44982/psn-pdf
    April 06, 2016 - Use of maternal early warning trigger tool reduces maternal morbidity. April 6, 2016 Shields LE, Wiesner S, Klein C, et al. Use of Maternal Early Warning Trigger tool reduces maternal morbidity. Am J Obstet Gynecol. 2016;214(4):527.e1-527.e6. doi:10.1016/j.ajog.2016.01.154. https://psnet.ahrq.gov/issue/use-materna…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38863/psn-pdf
    August 12, 2009 - Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications. August 12, 2009 Philibert I. Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications. Qual Saf Health Care. 2009;18(4):2…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48193/psn-pdf
    August 28, 2019 - Automated detection of wrong-drug prescribing errors. August 28, 2019 Lambert BL, Galanter W, Liu KL, et al. Automated detection of wrong-drug prescribing errors. BMJ Qual Saf. 2019;28(11):908-915. doi:10.1136/bmjqs-2019-009420. https://psnet.ahrq.gov/issue/automated-detection-wrong-drug-prescribing-errors Look-al…

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