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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46192/psn-pdf
    June 07, 2017 - Investigating the causes of adverse events. June 7, 2017 Sanchez JA, Lobdell KW, Moffatt-Bruce SD, et al. Investigating the Causes of Adverse Events. Ann Thorac Surg. 2017;103(6):1693-1699. doi:10.1016/j.athoracsur.2017.04.001. https://psnet.ahrq.gov/issue/investigating-causes-adverse-events Incident analysis enab…

  2. Psn-Pdf (pdf file)

    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…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41771/psn-pdf
    March 20, 2018 - Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide For Hospitals. March 20, 2018 Rockville, MD: Agency for Healthcare Research and Quality; September 2012. AHRQ Publication No. 12- 0041. https://psnet.ahrq.gov/issue/improving-patient-safety-systems-patients-limited-english-prof…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45391/psn-pdf
    August 10, 2016 - Where are my instruments? Hazards in delivery of surgical instruments. August 10, 2016 Guédon ACP, Wauben LSGL, van der Eijk AC, et al. Where are my instruments? Hazards in delivery of surgical instruments. Surg Endosc. 2016;30(7):2728-35. doi:10.1007/s00464-015-4537-7. https://psnet.ahrq.gov/issue/where-are-my-in…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44144/psn-pdf
    May 27, 2015 - Maintaining safety in the dialysis facility. May 27, 2015 Kliger AS. Maintaining safety in the dialysis facility. Clin J Am Soc Nephrol. 2015;10(4):688-95. doi:10.2215/CJN.08960914. https://psnet.ahrq.gov/issue/maintaining-safety-dialysis-facility Failure to consider human factors and poor communication can contri…

  6. Psn-Pdf (pdf file)

    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…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865883/psn-pdf
    May 15, 2024 - Addressing electronic health record contributions to diagnostic error. May 15, 2024 Ratwani RM, Bates DW, Gold J. Health Affairs Forefront. April 25, 2024. https://psnet.ahrq.gov/issue/addressing-electronic-health-record-contributions-diagnostic-error Design and user issues are persistent detractors from the relia…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35339/psn-pdf
    April 23, 2014 - Disclosing harmful medical errors to patients: a time for professional action. April 23, 2014 Gallagher TH, Levinson W. Disclosing Harmful Medical Errors to Patients. Arch Intern Med. 2005;165(16). doi:10.1001/archinte.165.16.1819. https://psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients-time-profes…

  9. Psn-Pdf (pdf file)

    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 …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36884/psn-pdf
    May 27, 2011 - Evaluation of outpatient computerized physician medication order entry systems: a systematic review. May 27, 2011 Eslami S, Abu-Hanna A, de Keizer NF. Evaluation of outpatient computerized physician medication order entry systems: a systematic review. J Am Med Inform Assoc. 2007;14(4):400-6. https://psnet.ahrq.gov…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42856/psn-pdf
    January 07, 2015 - Clinical benefits of electronic health record use: national findings. January 7, 2015 King J, Patel V, Jamoom EW, et al. Clinical benefits of electronic health record use: national findings. Health Serv Res. 2014;49(1 Pt 2):392-404. doi:10.1111/1475-6773.12135. https://psnet.ahrq.gov/issue/clinical-benefits-electr…

  12. Psn-Pdf (pdf file)

    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…

  13. Psn-Pdf (pdf file)

    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…

  14. Psn-Pdf (pdf file)

    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…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38644/psn-pdf
    May 20, 2009 - A quality initiative to decrease pathology specimen- labeling errors using radiofrequency identification in a high-volume endoscopy center. May 20, 2009 Francis DL, Prabhakar S, Sanderson SO. A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume en…

  16. Psn-Pdf (pdf file)

    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…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50568/psn-pdf
    October 23, 2019 - Automation of the I-PASS tool to improve transitions of care. October 23, 2019 Skaret MM, Weaver TD, Humes RJ, et al. Automation of the I-PASS Tool to Improve Transitions of Care. J Healthc Qual. 2019;41(5):274-280. doi:10.1097/JHQ.0000000000000174. https://psnet.ahrq.gov/issue/automation-i-pass-tool-improve-trans…

  18. Build a Business Case for Quality Improvement: Facilitator Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/mvp/modules/cusp/build-business-case-fac-guide.html
    February 01, 2017 - Build a Business Case for Quality Improvement: Facilitator Guide AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: Build a Business Case for Quality Improvement Say: This slide set introduces building a business case for quality improvement. Slide 2: Learning Objectives Say: Afte…

  19. AHRQ Final Progress Report: Developing an Integrated Engineering-Based Model to Reduce Infections in the ICU (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/mastrangelo-report.pdf
    January 01, 2024 - AHRQ Final Progress Report: Developing an Integrated Engineering-Based Model to Reduce Infections in the ICU AHRQ Final Progress Report Title: Developing an Integrated Engineering-Based Model to Reduce Infections in the ICU PI: Christina Mastrangelo Additional Team Members: Danielle Zerr & Shreyas Limaye Org…

  20. Privacy Gone Awry | PSNet

    psnet.ahrq.gov/web-mm/privacy-gone-awry
    February 24, 2011 - Privacy Gone Awry Citation Text: Pauker SG, Pauker SP. Privacy Gone Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubM…
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