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psnet.ahrq.gov/node/45013/psn-pdf
April 13, 2016 - Good Practice Guides on Medication Errors: Part 1 and
Part 2.
April 13, 2016
Goedecke T, Ord K, Newbould V, et al. Medication Errors: New Eu Good Practice Guide On Risk
Minimisation And Error Prevention. Springer Science and Business Media LLC; 2016. doi:10.1007/s40264-
016-0410-4.
https://psnet.ahrq.gov/issue/go…
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psnet.ahrq.gov/node/837735/psn-pdf
July 27, 2022 - A quality improvement initiative using peer audit and
feedback to improve compliance with the surgical safety
checklist.
July 27, 2022
Fridrich A, Imhof A, Staender S, et al. A quality improvement initiative using peer audit and feedback to
improve compliance. Int J Qual Health Care. 2022;34(3). doi:10.1093/intqhc…
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psnet.ahrq.gov/node/44688/psn-pdf
February 23, 2018 - Improving diagnosis in health care—the next imperative
for patient safety.
February 23, 2018
Singh H, Graber ML. Improving Diagnosis in Health Care--The Next Imperative for Patient Safety. New
Engl J Med. 2015;373(26):2493-2495. doi:10.1056/NEJMp1512241.
https://psnet.ahrq.gov/issue/improving-diagnosis-health-care…
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psnet.ahrq.gov/node/47083/psn-pdf
June 21, 2018 - Accuracy of skin cancer diagnosis by physician
assistants compared with dermatologists in a large health
care system.
June 21, 2018
Anderson AM, Matsumoto M, Saul MI, et al. Accuracy of Skin Cancer Diagnosis by Physician Assistants
Compared With Dermatologists in a Large Health Care System. JAMA Dermatol. 2018;154…
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psnet.ahrq.gov/node/46087/psn-pdf
September 24, 2017 - Who is responsible for the safe introduction of new
surgical technology? An important legal precedent from
the da Vinci Surgical System Trials.
September 24, 2017
Pradarelli J, Thornton JP, Dimick JB. Who Is Responsible for the Safe Introduction of New Surgical
Technology?: An Important Legal Precedent From the da…
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psnet.ahrq.gov/node/844765/psn-pdf
September 18, 2019 - Untangling infusion confusion: a comparative evaluation
of interventions in a simulated intensive care setting.
September 18, 2019
Pinkney SJ, Fan M, Koczmara C, et al. Untangling Infusion Confusion: A Comparative Evaluation of
Interventions in a Simulated Intensive Care Setting. Crit Care Med. 2019;47(7):e597-e601…
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psnet.ahrq.gov/node/46370/psn-pdf
November 08, 2017 - Standard admission order sets promote ordering of
unnecessary investigations: a quasi-randomised
evaluation in a simulated setting.
November 8, 2017
Leis B, Frost A, Bryce R, et al. Standard admission order sets promote ordering of unnecessary
investigations: a quasi-randomised evaluation in a simulated setting. B…
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psnet.ahrq.gov/node/46905/psn-pdf
October 13, 2018 - Association of hospital participation in a regional trauma
quality improvement collaborative with patient outcomes.
October 13, 2018
Hemmila MR, Cain-Nielsen AH, Jakubus JL, et al. Association of Hospital Participation in a Regional
Trauma Quality Improvement Collaborative With Patient Outcomes. JAMA Surg. 2018;153…
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psnet.ahrq.gov/node/60522/psn-pdf
May 27, 2020 - Nursing turbulence in critical care: relationships with
nursing workload and patient safety.
May 27, 2020
Browne J, Braden CJ. Nursing turbulence in critical care: relationships with nursing workload and patient
safety. Am J Crit Care. 2020;29(3):182-191. doi:10.4037/ajcc2020180.
https://psnet.ahrq.gov/issue/nursi…
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psnet.ahrq.gov/node/45230/psn-pdf
July 20, 2016 - Outcomes are worse in US patients undergoing surgery
on weekends compared with weekdays.
July 20, 2016
Glance LG, Osler T, Li Y, et al. Outcomes are Worse in US Patients Undergoing Surgery on Weekends
Compared With Weekdays. Med Care. 2016;54(6):608-15. doi:10.1097/MLR.0000000000000532.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/46835/psn-pdf
February 28, 2018 - Errors detected in pediatric oral liquid medication doses
prepared in an automated workflow management system.
February 28, 2018
Bledsoe S, Van Buskirk A, Falconer J, et al. Errors detected in pediatric oral liquid medication doses
prepared in an automated workflow management system. Am J Health Syst Pharm. 2018;75…
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psnet.ahrq.gov/node/48019/psn-pdf
June 26, 2019 - Please reconcile, not wait a while.
June 26, 2019
Trivedi A, Sharma S, Ajitsaria R, et al. Please reconcile, not wait a while. Arch Dis Child Educ Pract Ed.
2019;105(2):122-126. doi:10.1136/archdischild-2018-316356.
https://psnet.ahrq.gov/issue/please-reconcile-not-wait-while
Medication reconciliation to ensure ac…
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psnet.ahrq.gov/node/46066/psn-pdf
August 03, 2017 - The potential of collective intelligence in emergency
medicine.
August 3, 2017
Kämmer JE, Hautz WE, Herzog SM, et al. The Potential of Collective Intelligence in Emergency Medicine:
Pooling Medical Students' Independent Decisions Improves Diagnostic Performance. Med Decis Making.
2017;37(6):715-724. doi:10.1177/02…
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psnet.ahrq.gov/node/46873/psn-pdf
June 27, 2018 - Diagnostic errors and the bedside clinical examination.
June 27, 2018
Clark BW, Derakhshan A, Desai S. Diagnostic Errors and the Bedside Clinical Examination. Med Clin North
Am. 2018;102(3):453-464. doi:10.1016/j.mcna.2017.12.007.
https://psnet.ahrq.gov/issue/diagnostic-errors-and-bedside-clinical-examination
Diag…
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psnet.ahrq.gov/node/50651/psn-pdf
November 13, 2019 - How effective is teamwork really? The relationship
between teamwork and performance in healthcare teams:
a systematic review and meta-analysis.
November 13, 2019
Schmutz JB, Meier LL, Manser T. How effective is teamwork really? The relationship between teamwork
and performance in healthcare teams: a systematic rev…
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psnet.ahrq.gov/node/45432/psn-pdf
September 14, 2016 - Clinical decision support: a 25 year retrospective and a 25
year vision.
September 14, 2016
Middleton B, Sittig DF, Wright A. Clinical Decision Support: a 25 Year Retrospective and a 25 Year Vision.
Yearb Med Inform. 2016;Suppl 1:S103-16. doi:10.15265/IYS-2016-s034.
https://psnet.ahrq.gov/issue/clinical-decision-s…
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psnet.ahrq.gov/node/46133/psn-pdf
May 24, 2017 - Implementing smart infusion pumps with dose-error
reduction software: real-world experiences.
May 24, 2017
Heron C. Implementing smart infusion pumps with dose-error reduction software: real-world experiences.
Br J Nurs. 2017;26(8):S13-S16. doi:10.12968/bjon.2017.26.8.S13.
https://psnet.ahrq.gov/issue/implementing…
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psnet.ahrq.gov/node/44257/psn-pdf
November 06, 2015 - A systems approach to evaluating ionizing radiation: six
focus areas to improve quality, efficiency, and patient
safety.
November 6, 2015
Perlin JB, Mower L, Bushe C. A systems approach to evaluating ionizing radiation: six focus areas to
improve quality, efficiency, and patient safety. J Healthc Qual. 2015;37(3):…
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psnet.ahrq.gov/node/34694/psn-pdf
February 10, 2011 - Computerized surveillance of adverse drug events in
hospital patients.
February 10, 2011
Classen DC, Pestotnik SL, Evans RS, et al. Computerized surveillance of adverse drug events in hospital
patients. JAMA. 1991;266(20):2847-51.
https://psnet.ahrq.gov/issue/computerized-surveillance-adverse-drug-events-hospital-…
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psnet.ahrq.gov/node/43281/psn-pdf
May 28, 2015 - A method for prioritizing interventions following root
cause analysis (RCA): lessons from philosophy.
May 28, 2015
Boyd M. A method for prioritizing interventions following root cause analysis (RCA): lessons from
philosophy. J Eval Clin Pract. 2015;21(3):461-9. doi:10.1111/jep.12272.
https://psnet.ahrq.gov/issue/m…