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psnet.ahrq.gov/node/44943/psn-pdf
April 15, 2016 - Evaluation of frequency of paediatric oral liquid
medication dosing errors by caregivers: amoxicillin and
josamycin.
April 15, 2016
Berthe-Aucejo A, Girard D, Lorrot M, et al. Evaluation of frequency of paediatric oral liquid medication
dosing errors by caregivers: amoxicillin and josamycin. Arch Dis Child. 2016;1…
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psnet.ahrq.gov/node/47979/psn-pdf
May 01, 2019 - Inpatient notes: just what the doctor ordered—checklists
to improve diagnosis.
May 1, 2019
Gupta A, Graber ML. Web Exclusive. Annals for Hospitalists Inpatient Notes - Just What the Doctor
Ordered-Checklists to Improve Diagnosis. Ann Intern Med. 2019;170(8):HO2-HO3. doi:10.7326/M19-0829.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/44080/psn-pdf
September 27, 2017 - A descriptive study of nurse-reported missed care in
neonatal intensive care units.
September 27, 2017
Tubbs-Cooley HL, Pickler RH, Younger JB, et al. A descriptive study of nurse-reported missed care in
neonatal intensive care units. J Adv Nurs. 2015;71(4):813-24. doi:10.1111/jan.12578.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/46938/psn-pdf
April 25, 2018 - Diagnostic reasoning and cognitive biases of nurse
practitioners.
April 25, 2018
Lawson TN. Diagnostic Reasoning and Cognitive Biases of Nurse Practitioners. J Nurs Educ.
2018;57(4):203-208. doi:10.3928/01484834-20180322-03.
https://psnet.ahrq.gov/issue/diagnostic-reasoning-and-cognitive-biases-nurse-practitioners…
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psnet.ahrq.gov/node/44795/psn-pdf
June 29, 2016 - Human factors in healthcare: welcome progress, but still
scratching the surface.
June 29, 2016
Waterson P, Catchpole K. Human factors in healthcare: welcome progress, but still scratching the surface.
BMJ Qual Saf. 2016;25(7):480-4. doi:10.1136/bmjqs-2015-005074.
https://psnet.ahrq.gov/issue/human-factors-healthca…
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psnet.ahrq.gov/node/47800/psn-pdf
June 26, 2019 - Error and Uncertainty in Diagnostic Radiology.
June 26, 2019
Bruno MA. New York, NY: Oxford University Press; 2019. ISBN: 9780190665395.
https://psnet.ahrq.gov/issue/error-and-uncertainty-diagnostic-radiology
Despite enhancements in medical imaging technology, diagnostic radiologists are still susceptible to
uncer…
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psnet.ahrq.gov/node/846761/psn-pdf
September 29, 2018 - Using clinical simulation to study how to improve quality
and safety in healthcare.
September 29, 2018
Lamé G, Dixon-Woods M. Using clinical simulation to study how to improve quality and safety in
healthcare. BMJ Simul Technol Enhanc Learn. 2018;6(2):87-94. doi:10.1136/bmjstel-2018-000370.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/43980/psn-pdf
March 18, 2015 - Adapting The Joint Commission's seven foundations of
safe and effective transitions of care to home.
March 18, 2015
Labson MC. Adapting the joint commission's seven foundations of safe and effective transitions of care to
home. Home Healthc Now. 2015;33(3):142-6. doi:10.1097/NHH.0000000000000195.
https://psnet.ahr…
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psnet.ahrq.gov/node/42784/psn-pdf
January 15, 2014 - A multi-disciplinary approach to medication safety and
the implication for nursing education and practice.
January 15, 2014
Adhikari R, Tocher J, Smith P, et al. A multi-disciplinary approach to medication safety and the implication
for nursing education and practice. Nurse Educ Today. 2014;34(2):185-90. doi:10.101…
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psnet.ahrq.gov/node/45271/psn-pdf
August 10, 2016 - Patient identification and tube labelling—a call for
harmonisation.
August 10, 2016
van Dongen-Lases EC, Cornes MP, Grankvist K, et al. Patient identification and tube labelling – a call for
harmonisation. Clinical Chemistry and Laboratory Medicine (CCLM). 2016;54(7). doi:10.1515/cclm-2015-
1089.
https://psnet.ah…
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psnet.ahrq.gov/node/838312/psn-pdf
October 12, 2022 - Causes of adverse events in home mechanical
ventilation: a nursing perspective.
October 12, 2022
Lipprandt M, Liedtke W, Langanke M, et al. Causes of adverse events in home mechanical ventilation: a
nursing perspective. BMC Nurs. 2022;21(1):264. doi:10.1186/s12912-022-01038-2.
https://psnet.ahrq.gov/issue/causes-a…
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psnet.ahrq.gov/node/45632/psn-pdf
November 30, 2016 - Simulation for operational readiness in a new
freestanding emergency department: strategy and tactics.
November 30, 2016
Kerner RL, Gallo K, Cassara M, et al. Simulation for Operational Readiness in a New Freestanding
Emergency Department. Simul Healthc. 2016;11(5). doi:10.1097/sih.0000000000000180.
https://psnet.…
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psnet.ahrq.gov/node/45034/psn-pdf
February 25, 2019 - Future directions for diagnostic decision support.
February 25, 2019
Carr S. ImproveDx. April 2016;3:1-3.
https://psnet.ahrq.gov/issue/future-directions-diagnostic-decision-support
Clinical decision support systems are tools being used to augment clinical reasoning and diagnostic
accuracy. This newsletter article …
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psnet.ahrq.gov/node/46548/psn-pdf
April 16, 2018 - Nurses' communication of safety events to nursing home
residents and families.
April 16, 2018
Wagner LM, Driscoll L, Darlington JL, et al. Nurses' Communication of Safety Events to Nursing Home
Residents and Families. J Gerontol Nurs. 2018;44(2):25-32. doi:10.3928/00989134-20171002-01.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/44439/psn-pdf
September 16, 2015 - Color-coded prefilled medication syringes decrease time
to delivery and dosing errors in simulated prehospital
pediatric resuscitations: a randomized crossover trial.
September 16, 2015
Stevens AD, Hernandez C, Jones S, et al. Color-coded prefilled medication syringes decrease time to
delivery and dosing errors in…
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psnet.ahrq.gov/node/44118/psn-pdf
May 19, 2018 - Inadequate preoperative team briefings lead to more
intraoperative adverse events.
May 19, 2018
Phadnis J, Templeton-Ward O. Inadequate Preoperative Team Briefings Lead to More Intraoperative
Adverse Events. J Patient Saf. 2018;14(2):82-86. doi:10.1097/PTS.0000000000000181.
https://psnet.ahrq.gov/issue/inadequate-…
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psnet.ahrq.gov/node/44234/psn-pdf
September 09, 2015 - Improving the reliability of verbal communication between
primary care physicians and pediatric hospitalists at
hospital discharge.
September 9, 2015
Mussman GM, Vossmeyer MT, Brady PW, et al. Improving the reliability of verbal communication between
primary care physicians and pediatric hospitalists at hospital d…
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psnet.ahrq.gov/node/46934/psn-pdf
March 14, 2018 - Engaging the front line: tapping into hospital-wide quality
and safety initiatives.
March 14, 2018
Wolpaw J, Schwengel D, Hensley N, et al. Engaging the Front Line: Tapping into Hospital-Wide Quality
and Safety Initiatives. J Cardiothorac Vasc Anesth. 2018;32(1):522-533. doi:10.1053/j.jvca.2017.05.038.
https://psn…
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psnet.ahrq.gov/node/836726/psn-pdf
March 09, 2022 - OpenNotes and patient safety: a perilous voyage into
uncharted waters.
March 9, 2022
Schust G, Manning M, Weil A. OpenNotes and patient safety: a perilous voyage into uncharted waters. J
Gen Intern Med. 2022;37(8):2074-2076. doi:10.1007/s11606-021-07384-2.
https://psnet.ahrq.gov/issue/opennotes-and-patient-safety-…
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psnet.ahrq.gov/node/73170/psn-pdf
April 21, 2021 - Sentinel Event Alert 63: optimizing smart infusion pump
safety with DERS.
April 21, 2021
Sentinel Event Alert 63: Optimizing Smart Infusion Pump Safety with DERS. Jt Comm J Qual Patient Saf.
2021;47(6):394-397. doi:10.1016/j.jcjq.2021.03.013.
https://psnet.ahrq.gov/issue/sentinel-event-alert-63-optimizing-smart-in…