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psnet.ahrq.gov/node/846167/psn-pdf
March 15, 2023 - Diagnostic stewardship to prevent diagnostic error.
March 15, 2023
Morgan DJ, Malani PN, Diekema DJ. Diagnostic stewardship to prevent diagnostic error. JAMA.
2023;329(15):1255-1256. doi:10.1001/jama.2023.1678.
https://psnet.ahrq.gov/issue/diagnostic-stewardship-prevent-diagnostic-error
The effective use of resour…
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psnet.ahrq.gov/node/72734/psn-pdf
February 10, 2021 - Meitheal Pharmaceuticals, Inc. issues voluntary
nationwide recall of Cisatracurium Besylate Injection,
USP 10mg per 5mL due to mislabeling.
February 10, 2021
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 27, 2021.
https://psnet.ahrq.gov/issue/meitheal-pharmaceuticals-inc…
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psnet.ahrq.gov/node/45569/psn-pdf
January 23, 2017 - Patient experience must move beyond bad apples.
January 23, 2017
Hamedani A, Safdar B, Aaronson E, et al. Patient Experience Must Move Beyond Bad Apples. Ann Intern
Med. 2016;165(12):869-870. doi:10.7326/M16-1725.
https://psnet.ahrq.gov/issue/patient-experience-must-move-beyond-bad-apples
Patient safety leaders ha…
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psnet.ahrq.gov/node/60192/psn-pdf
April 01, 2020 - Effective Reporting Could Improve Safe Use of Electronic
Health Records.
April 1, 2020
Philadelphia, PA: Pew Charitable Trusts; March 2020.
https://psnet.ahrq.gov/issue/effective-reporting-could-improve-safe-use-electronic-health-records
Electronic health records both enhance and challenge the safety of care proce…
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psnet.ahrq.gov/node/42346/psn-pdf
June 10, 2018 - Fatal PCA adverse events continue to happen...better
patient monitoring is essential to prevent harm.
June 10, 2018
ISMP Medication Safety Alert! Acute Care Edition. May 30, 2013;18:1-3.
https://psnet.ahrq.gov/issue/fatal-pca-adverse-events-continue-happenbetter-patient-monitoring-essential-
prevent-harm
Describi…
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psnet.ahrq.gov/node/73255/psn-pdf
May 12, 2021 - Implementing High-Quality Primary Care: Rebuilding the
Foundation of Health Care.
May 12, 2021
National Academies of Sciences, Engineering, and Medicine 2021. Washington, DC: The National
Academies Press.
https://psnet.ahrq.gov/issue/implementing-high-quality-primary-care-rebuilding-foundation-health-care
Primary…
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psnet.ahrq.gov/node/46104/psn-pdf
May 03, 2017 - Secret data on hospital inspections may soon become
public.
May 3, 2017
Ornstein C. Health Shots. National Public Radio and ProPublica. April 18, 2017.
https://psnet.ahrq.gov/issue/secret-data-hospital-inspections-may-soon-become-public
Summary data about serious errors in hospitals are available, but often detail…
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psnet.ahrq.gov/node/866567/psn-pdf
August 21, 2024 - A daily dose of communication to improve quality and
safety outcomes.
August 21, 2024
Halm MA. A daily dose of communication to improve quality and safety outcomes. Am J Crit Care.
2024;33(4):305-310. doi:10.4037/ajcc2024318.
https://psnet.ahrq.gov/issue/daily-dose-communication-improve-quality-and-safety-outcomes…
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psnet.ahrq.gov/node/73861/psn-pdf
September 22, 2021 - Bringing the clinical laboratory into the strategy to
advance diagnostic excellence.
September 22, 2021
Lubin IM, Astles J R, Shahangian S, et al. Bringing the clinical laboratory into the strategy to advance
diagnostic excellence. Diagnosis (Berl). 2021;8(3):281-294. doi:10.1515/dx-2020-0119.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/48167/psn-pdf
August 28, 2019 - ASHP guidelines on perioperative pharmacy services.
August 28, 2019
Bickham P, Golembiewski J, Meyer T, et al. ASHP guidelines on perioperative pharmacy services. Am J
Health Syst Pharm. 2019;76(12):903-820. doi:10.1093/ajhp/zxz073.
https://psnet.ahrq.gov/issue/ashp-guidelines-perioperative-pharmacy-services
Pharm…
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psnet.ahrq.gov/node/39572/psn-pdf
January 03, 2017 - The tangible handoff: a team approach for advancing
structured communication in labor and delivery.
January 3, 2017
Block M, Ehrenworth JF, Cuce VM, et al. The tangible handoff: a team approach for advancing structured
communication in labor and delivery. Jt Comm J Qual Patient Saf. 2010;36(6):282-287, 241.
https:…
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psnet.ahrq.gov/node/45958/psn-pdf
January 01, 2021 - The effects of bar-coding technology on medication
errors: a systematic literature review.
April 19, 2017
Hutton K, Ding Q, Wellman G. The Effects of Bar-coding Technology on Medication Errors: A Systematic
Literature Review. J Patient Saf. 2021;17(3):e192-e206. doi:10.1097/PTS.0000000000000366.
https://psnet.ahrq…
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psnet.ahrq.gov/node/42415/psn-pdf
July 24, 2013 - Strategies for improving communication in the
emergency department: mediums and messages in a
noisy environment.
July 24, 2013
Welch SJ, Cheung DS, Apker J, et al. Strategies for improving communication in the emergency
department: mediums and messages in a noisy environment. Jt Comm J Qual Patient Saf. 2013;39(6)…
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psnet.ahrq.gov/node/844792/psn-pdf
January 01, 2020 - Surgical data recording technology: a solution to address
medical errors?
September 18, 2019
Shah NA, Jue J, Mackey T. Surgical Data Recording Technology. Ann Surg. 2020;271(3):431-433.
doi:10.1097/sla.0000000000003510.
https://psnet.ahrq.gov/issue/surgical-data-recording-technology-solution-address-medical-errors…
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psnet.ahrq.gov/node/842777/psn-pdf
January 18, 2023 - Patient safety performance: reversing recent declines
through shared profession-wide system-level solutions.
January 18, 2023
doi:full/10.1056/CAT.22.0318.
https://psnet.ahrq.gov/issue/patient-safety-performance-reversing-recent-declines-through-shared-
profession-wide-system
The COVID-19 pandemic revealed fractu…
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psnet.ahrq.gov/node/38409/psn-pdf
May 21, 2009 - The state of the evidence for computerized provider order
entry: a systematic review and analysis of the quality of
the literature.
May 21, 2009
Weir C, Staggers N, Phansalkar S. The state of the evidence for computerized provider order entry: a
systematic review and analysis of the quality of the literature. Int …
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psnet.ahrq.gov/node/39197/psn-pdf
January 06, 2010 - root-cause-analysis
https://psnet.ahrq.gov/primer/never-events
https://psnet.ahrq.gov/issue/resident-duty-hours-enhancing-sleep-supervision-and-safety
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psnet.ahrq.gov/node/43027/psn-pdf
July 23, 2014 - improving-team-information-sharing-structured-call-out-anaesthetic-emergencies-randomized
https://psnet.ahrq.gov/issue/enhancing-patient-safety-during-hand-offs-standardized-communication-and-teamwork-using-sbar
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psnet.ahrq.gov/node/44513/psn-pdf
September 23, 2015 - recommendations to improve diagnosis, including promoting teamwork among interdisciplinary health care
teams, enhancing
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psnet.ahrq.gov/node/47516/psn-pdf
December 19, 2018 - Diverse stakeholders in Australia established an agenda for enhancing test result management,
which