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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
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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.…
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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…
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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…
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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.…
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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…
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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-…
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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.…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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psnet.ahrq.gov/issue/patient-safety-group
March 27, 2024 - Multi-use Website
The Patient Safety Group.
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August 9, 2006
Development of The Patient Safety Group was motivated by the death of…
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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…
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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…
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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
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