-
psnet.ahrq.gov/node/43662/psn-pdf
November 05, 2014 - A crack in our best armor: "wrong patient" injections from
insulin pens alarmingly frequent even with barcode
scanning.
November 5, 2014
ISMP Medication Safety Alert! Acute Care Edition. October 23, 2014;19:1-5.
https://psnet.ahrq.gov/issue/crack-our-best-armor-wrong-patient-injections-insulin-pens-alarmingly-
fr…
-
psnet.ahrq.gov/node/60939/psn-pdf
September 23, 2020 - Does increased schedule flexibility lead to change? A
national survey of program directors on 2017 work hours
requirements.
September 23, 2020
Finn KM, Halvorsen AJ, Chaudhry S, et al. Does increased schedule flexibility lead to change? A national
survey of program directors on 2017 work hours requirements. J Gen …
-
psnet.ahrq.gov/node/48119/psn-pdf
August 07, 2019 - Improving perceptions of patient safety through
standardizing handoffs from the emergency department
to the inpatient setting: a systematic review.
August 7, 2019
Alimenti D, Buydos S, Cunliffe L, et al. Improving perceptions of patient safety through standardizing
handoffs from the emergency department to the inp…
-
psnet.ahrq.gov/node/40079/psn-pdf
December 18, 2014 - Adverse events from cough and cold medications after a
market withdrawal of products labeled for infants.
December 18, 2014
Shehab N, Schaefer MK, Kegler SR, et al. Adverse events from cough and cold medications after a market
withdrawal of products labeled for infants. Pediatrics. 2010;126(6):1100-7. doi:10.1542/p…
-
psnet.ahrq.gov/node/36254/psn-pdf
February 02, 2011 - Extended work duration and the risk of self-reported
percutaneous injuries in interns.
February 2, 2011
Ayas N, Barger LK, Cade BE, et al. Extended work duration and the risk of self-reported percutaneous
injuries in interns. JAMA. 2006;296(9):1055-62.
https://psnet.ahrq.gov/issue/extended-work-duration-and-risk-s…
-
psnet.ahrq.gov/node/40743/psn-pdf
February 01, 2019 - Radiation risks of diagnostic imaging and fluoroscopy.
December 23, 2016
Sentinel Event Alert. August 24, 2011;47:1-4. (revised February 2019).
https://psnet.ahrq.gov/issue/radiation-risks-diagnostic-imaging
The Joint Commission issues Sentinel Event Alerts periodically to highlight emerging patient safety issues
…
-
psnet.ahrq.gov/node/848038/psn-pdf
April 26, 2023 - Assessing system thinking in senior pharmacy students
using the innovative "Horror Room" simulation setting: a
cross-sectional survey of a non-technical skill.
April 26, 2023
Aljuffali LA, Almalag HM, Alnaim L. Assessing system thinking in senior pharmacy students using the
innovative "Horror Room" simulation sett…
-
psnet.ahrq.gov/node/36675/psn-pdf
January 18, 2011 - Target-focused medical emergency team training using a
human patient simulator: effects on behaviour and
attitude.
January 18, 2011
Wallin C-J, Meurling L, Hedman L, et al. Target-focused medical emergency team training using a human
patient simulator: effects on behaviour and attitude. Med Educ. 2007;41(2):173-80…
-
psnet.ahrq.gov/node/60844/psn-pdf
August 26, 2020 - Surgical errors happen, but are learners trained to
recover from them? A survey of North American surgical
residents and fellows.
August 26, 2020
Gabrysz-Forget F, Young M, Zahabi S, et al. Surgical errors happen, but are learners trained to recover
from them? A survey of North American surgical residents and fell…
-
psnet.ahrq.gov/node/838252/psn-pdf
October 05, 2022 - A longitudinal study of a multifaceted intervention to
reduce newborn falls while preserving rooming-in on a
mother-baby unit.
October 5, 2022
Whatley C, Schlogl J, Whalen BL, et al. A longitudinal study of a multifaceted intervention to reduce
newborn falls while preserving rooming-in on a mother-baby unit. Jt Co…
-
psnet.ahrq.gov/node/73955/psn-pdf
October 13, 2021 - The efficacy of mindful practice in improving diagnosis in
healthcare: a systematic review and evidence synthesis.
October 13, 2021
Pinnock R, Ritchie D, Gallagher S, et al. The efficacy of mindful practice in improving diagnosis in
healthcare: a systematic review and evidence synthesis. Adv Health Sci Educ Theory …
-
psnet.ahrq.gov/node/39745/psn-pdf
September 09, 2010 - Duty hours in emergency medicine: balancing patient
safety, resident wellness, and the resident training
experience: a consensus response to the 2008 Institute of
Medicine resident duty hours recommendations.
September 9, 2010
Wagner MJ, Wolf S, Promes S, et al. Duty hours in emergency medicine: balancing patient …
-
psnet.ahrq.gov/node/867014/psn-pdf
October 23, 2024 - Secondary analysis of hand-offs in internal medicine
using the I-PASS mnemonic.
October 23, 2024
Huber A, Moyano B, Blondon K. Secondary analysis of hand-offs in internal medicine using the I-PASS
mnemonic. BMC Med Educ. 2024;24(1):1046. doi:10.1186/s12909-024-05880-7.
https://psnet.ahrq.gov/issue/secondary-analys…
-
psnet.ahrq.gov/node/46561/psn-pdf
November 22, 2017 - Working with influenza-like illness: presenteeism among
US health care personnel during the 2014–2015 influenza
season.
November 22, 2017
Chiu S, Black CL, Yue X, et al. Working with influenza-like illness: Presenteeism among US health care
personnel during the 2014-2015 influenza season. Am J Infect Control. 2017…
-
psnet.ahrq.gov/node/837741/psn-pdf
July 27, 2022 - The impact of a 22-month multistep implementation
program on speaking-up behavior in an academic
anesthesia department.
July 27, 2022
Walther F, Schick C, Schwappach DLB, et al. The impact of a 22-month multistep implementation program
on speaking-up behavior in an academic anesthesia department. J Patient Saf. 20…
-
psnet.ahrq.gov/node/47755/psn-pdf
July 24, 2019 - Animated stories of medical error as a means of teaching
undergraduates patient safety: an evaluation study.
July 24, 2019
Cooper K, Hatfield E, Yeomans J. Animated stories of medical error as a means of teaching
undergraduates patient safety: an evaluation study. Perspect Med Edu. 2019;8(2):118-122.
doi:10.1007/s…
-
www.uspreventiveservicestaskforce.org/home/getfilebytoken/_dWYJfcG72H8QZsMWsPgcq
Figure. Primary Care Interventions to Support Breastfeeding: Clinical Summary
Figure. Primary Care Interventions to Support Breastfeeding: Clinical Summary
Population Pregnant women, new mothers, and their children
Recommendation
Provide interventions during pregnancy and after birth to support breastf…
-
digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/GroundRulesForConductingaRiskAssessment.pdf
January 01, 2010 - Ground rules for conducting a proactive risk assessment
Ground Rules for Conducting a Risk Assessment
• Clearly define the process. (For example, “followup for high risk diabetics.”)
• Limit the scope. (For example, “diabetics with poor compliance.”)
• Ensure that the process selected is relevant to the health …
-
psnet.ahrq.gov/node/867687/psn-pdf
March 05, 2025 - Simulation-debriefing enhanced needs assessment to
address quality markers in health care: an innovation for
prospective hazard analysis.
March 5, 2025
Barker LT, Bond WF, Willemsen-Dunlap AM, et al. Simulation-debriefing enhanced needs assessment to
address quality markers in health care: an innovation for prospe…
-
psnet.ahrq.gov/node/60045/psn-pdf
March 18, 2020 - Making Healthcare Safer III.
March 18, 2020
Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March
2020. AHRQ Publication No. 20-0029-EF.
https://psnet.ahrq.gov/issue/making-healthcare-safer-iii
This newly issued follow up to the seminal AHRQ Making Health Care Safer rep…