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psnet.ahrq.gov/node/39337/psn-pdf
May 07, 2014 - Clinical and economic outcomes attributable to health
care–associated sepsis and pneumonia.
May 7, 2014
Eber MR, Laxminarayan R, Perencevich E, et al. Clinical and economic outcomes attributable to health
care-associated sepsis and pneumonia. Arch Intern Med. 2010;170(4):347-53.
doi:10.1001/archinternmed.2009.509.…
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psnet.ahrq.gov/node/38076/psn-pdf
February 15, 2011 - Consequences of inadequate sign-out for patient care.
February 15, 2011
Horwitz LI, Moin T, Krumholz HM, et al. Consequences of inadequate sign-out for patient care. Arch Intern
Med. 2008;168(16):1755-60. doi:10.1001/archinte.168.16.1755.
https://psnet.ahrq.gov/issue/consequences-inadequate-sign-out-patient-care
W…
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psnet.ahrq.gov/node/44208/psn-pdf
July 16, 2015 - Preventability of voluntarily reported or trigger
tool–identified medication errors in a pediatric institution
by information technology: a retrospective cohort study.
July 16, 2015
Stultz JS, Nahata MC. Preventability of Voluntarily Reported or Trigger Tool-Identified Medication Errors in
a Pediatric Institution …
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psnet.ahrq.gov/node/40640/psn-pdf
December 01, 2011 - Safety hazards in cancer care: findings using three
different methods.
December 1, 2011
Lipczak H, Knudsen JL, Nissen A. Safety hazards in cancer care: findings using three different methods.
BMJ Qual Saf. 2011;20(12):1052-6. doi:10.1136/bmjqs.2010.050856.
https://psnet.ahrq.gov/issue/safety-hazards-cancer-care-fi…
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psnet.ahrq.gov/node/43617/psn-pdf
September 24, 2016 - Do telephone call interruptions have an impact on
radiology resident diagnostic accuracy?
September 24, 2016
Balint BJ, Steenburg SD, Lin H, et al. Do telephone call interruptions have an impact on radiology resident
diagnostic accuracy? Acad Radiol. 2014;21(12):1623-8. doi:10.1016/j.acra.2014.08.001.
https://psne…
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psnet.ahrq.gov/node/41339/psn-pdf
January 03, 2017 - Relationship between nursing home safety culture and
Joint Commission accreditation.
January 3, 2017
Wagner LM, McDonald SM, Castle NG. Relationship between nursing home safety culture and Joint
Commission accreditation. Jt Comm J Qual Patient Saf. 2012;38(5):207-15.
https://psnet.ahrq.gov/issue/relationship-betwe…
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psnet.ahrq.gov/node/44064/psn-pdf
November 03, 2015 - The July effect: an analysis of never events in the
nationwide inpatient sample.
November 3, 2015
Wen T, Attenello FJ, Wu B, et al. The July effect: an analysis of never events in the nationwide inpatient
sample. J Hosp Med. 2015;10(7):432-438. doi:10.1002/jhm.2352.
https://psnet.ahrq.gov/issue/july-effect-analysi…
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psnet.ahrq.gov/node/45141/psn-pdf
August 31, 2016 - Patient safety climate strength: a concept that requires
more attention.
August 31, 2016
Ginsburg LR, Oore DG. Patient safety climate strength: a concept that requires more attention. BMJ Qual
Saf. 2016;25(9):680-7. doi:10.1136/bmjqs-2015-004150.
https://psnet.ahrq.gov/issue/patient-safety-climate-strength-concept…
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psnet.ahrq.gov/node/844790/psn-pdf
January 01, 2020 - Effectiveness of double checking to reduce medication
administration errors: a systematic review.
September 18, 2019
Koyama AK, Maddox C-SS, Li L, et al. Effectiveness of double checking to reduce medication
administration errors: a systematic review. BMJ Qual Saf. 2020;29(7):595-603. doi:10.1136/bmjqs-2019-
00955…
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psnet.ahrq.gov/node/45719/psn-pdf
June 29, 2017 - Systematic review of the prevalence of medication errors
resulting in hospitalization and death of nursing home
residents.
June 29, 2017
Ferrah N, Lovell JJ, Ibrahim JE. Systematic Review of the Prevalence of Medication Errors Resulting in
Hospitalization and Death of Nursing Home Residents. J Am Geriatr Soc. 2017…
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psnet.ahrq.gov/node/39730/psn-pdf
December 21, 2014 - Surgical case listing accuracy: failure analysis at a high-
volume academic medical center.
December 21, 2014
Cima RR, Hale C, Kollengode A, et al. Surgical case listing accuracy: failure analysis at a high-volume
academic medical center. Arch Surg. 2010;145(7):641-6. doi:10.1001/archsurg.2010.112.
https://psnet.a…
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psnet.ahrq.gov/node/38354/psn-pdf
September 24, 2010 - Barriers to emergency departments' adherence to four
medication safety–related Joint Commission National
Patient Safety Goals.
September 24, 2010
Juarez A, Gacki-Smith J, Bauer MR, et al. Barriers to emergency departments' adherence to four
medication safety-related Joint Commission National Patient Safety Goals. …
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psnet.ahrq.gov/node/40766/psn-pdf
September 14, 2011 - Medicines reconciliation using a shared electronic health
care record.
September 14, 2011
Moore P, Armitage G, Wright J, et al. Medicines reconciliation using a shared electronic health care record.
J Patient Saf. 2011;7(3):148-154. doi:10.1097/PTS.0b013e31822c5bf9.
https://psnet.ahrq.gov/issue/medicines-reconcili…
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psnet.ahrq.gov/node/40052/psn-pdf
December 08, 2010 - Electronic health records and adverse drug events after
patient transfer.
December 8, 2010
Boockvar KS, Livote EE, Goldstein N, et al. Electronic health records and adverse drug events after patient
transfer. Qual Saf Health Care. 2010;19(5):e16. doi:10.1136/qshc.2009.033050.
https://psnet.ahrq.gov/issue/electroni…
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psnet.ahrq.gov/node/45988/psn-pdf
April 24, 2018 - Translating concerns into action: a detailed qualitative
evaluation of an interdisciplinary intervention on medical
wards.
April 24, 2018
Pannick S, Archer S, Johnston MJ, et al. Translating concerns into action: a detailed qualitative evaluation
of an interdisciplinary intervention on medical wards. BMJ Open. 201…
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psnet.ahrq.gov/node/36168/psn-pdf
August 31, 2011 - Computerized prescribing alerts and group academic
detailing to reduce the use of potentially inappropriate
medications in older people.
August 31, 2011
Simon SR, Smith DH, Feldstein AC, et al. Computerized prescribing alerts and group academic detailing to
reduce the use of potentially inappropriate medications i…
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psnet.ahrq.gov/node/45882/psn-pdf
June 28, 2017 - Early death after discharge from emergency departments:
analysis of national US insurance claims data.
June 28, 2017
Obermeyer Z, Cohn B, Wilson M, et al. Early death after discharge from emergency departments: analysis
of national US insurance claims data. BMJ. 2017;356:j239. doi:10.1136/bmj.j239.
https://psnet.a…
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psnet.ahrq.gov/node/40189/psn-pdf
February 02, 2011 - Addition of electronic prescription transmission to
computerized prescriber order entry: effect on dispensing
errors in community pharmacies.
February 2, 2011
Moniz TT, Seger AC, Keohane CA, et al. Addition of electronic prescription transmission to computerized
prescriber order entry: Effect on dispensing errors …
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psnet.ahrq.gov/node/37363/psn-pdf
February 03, 2011 - Effect of a rapid response team on hospital-wide mortality
and code rates outside the ICU in a children’s hospital.
February 3, 2011
Sharek PJ, Parast L, Leong K, et al. Effect of a rapid response team on hospital-wide mortality and code
rates outside the ICU in a Children's Hospital. JAMA. 2007;298(19):2267-74.
h…
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psnet.ahrq.gov/node/47102/psn-pdf
June 26, 2018 - Transition to a new electronic health record and pediatric
medication safety: lessons learned in pediatrics within a
large academic health system.
June 26, 2018
Whalen K, Lynch E, Moawad I, et al. Transition to a new electronic health record and pediatric medication
safety: lessons learned in pediatrics within a l…