-
psnet.ahrq.gov/node/44384/psn-pdf
August 12, 2015 - Effective followership: a standardized algorithm to
resolve clinical conflicts and improve teamwork.
August 12, 2015
Sculli GL, Fore AM, Sine DM, et al. Effective followership: A standardized algorithm to resolve clinical
conflicts and improve teamwork. J Healthc Risk Manag. 2015;35(1):21-30. doi:10.1002/jhrm.21174…
-
psnet.ahrq.gov/node/46792/psn-pdf
February 14, 2018 - Emerging trends in perinatal quality and risk with
recommendations for patient safety.
February 14, 2018
Simpson KR. Emerging Trends in Perinatal Quality and Risk With Recommendations for Patient Safety. J
Perinat Neonatal Nurs. 2018;32(1). doi:10.1097/jpn.0000000000000294.
https://psnet.ahrq.gov/issue/emerging-tr…
-
psnet.ahrq.gov/node/849123/psn-pdf
May 17, 2023 - Maximizing student potential: lessons for pharmacy
programs from the patient safety movement.
May 17, 2023
Abebe E, Bao A, Kokkinias P, et al. Maximizing student potential: lessons for pharmacy programs from the
patient safety movement. Explor Res Clin Soc Pharm. 2023;9:100216. doi:10.1016/j.rcsop.2022.100216.
htt…
-
psnet.ahrq.gov/node/861292/psn-pdf
January 24, 2024 - Deficiencies in the Community Care Network
Credentialing Process of a Former VA Surgeon and
Veterans Health Administration Oversight Failures.
January 24, 2024
Washington DC: VA Office of the Inspector General; January 4, 2024; Report no. 22-02294-42.
https://psnet.ahrq.gov/issue/deficiencies-community-care-n…
-
psnet.ahrq.gov/node/46707/psn-pdf
October 13, 2018 - Medication errors involving nursing students: a
systematic review.
October 13, 2018
Asensi-Vicente J, Jiménez-Ruiz I, Vizcaya-Moreno F. Medication Errors Involving Nursing Students: A
Systematic Review. Nurse Educ. 2018;43(5):E1-E5. doi:10.1097/NNE.0000000000000481.
https://psnet.ahrq.gov/issue/medication-errors-i…
-
psnet.ahrq.gov/node/838193/psn-pdf
September 28, 2022 - Economics of Medication Safety. Improving Medication
Safety Through Collective, Real-time Learning.
September 28, 2022
de Bienassis K, Esmail L, Lopert R, Klazinga N for the Organisation for Economic Co-operation and
Development. Paris, France: OECD Publishing; 2022. OECD Health Working Papers, No. 147.
…
-
psnet.ahrq.gov/node/60697/psn-pdf
July 15, 2020 - FDA alerts health care professionals to the temporary
absence of warning statement on the vial caps of two
neuromuscular blocking agents.
July 15, 2020
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. June 2, 2020.
https://psnet.ahrq.gov/issue/fda-alerts-health-care-professionals-temporar…
-
psnet.ahrq.gov/node/47586/psn-pdf
March 20, 2019 - Wrong-patient blood transfusion error: leveraging
technology to overcome human error in intraoperative
blood component administration.
March 20, 2019
Hensley NB, Koch CG, Pronovost P, et al. Wrong-Patient Blood Transfusion Error: Leveraging Technology
to Overcome Human Error in Intraoperative Blood Component Admin…
-
psnet.ahrq.gov/node/43257/psn-pdf
August 14, 2014 - Barriers and success factors to the implementation of a
multi-site prospective adverse event surveillance system.
August 14, 2014
Backman C, Forster AJ, Vanderloo S. Barriers and success factors to the implementation of a multi-site
prospective adverse event surveillance system. Int J Qual Health Care. 2014;26(4):4…
-
psnet.ahrq.gov/node/43162/psn-pdf
June 16, 2014 - The use of report cards and outcome measurements to
improve the safety of surgical care: the American College
of Surgeons National Surgical Quality Improvement
Program.
June 16, 2014
Maggard-Gibbons M. The use of report cards and outcome measurements to improve the safety of surgical
care: the American College of…
-
psnet.ahrq.gov/node/44663/psn-pdf
September 27, 2016 - Impact of regionalized care on concordance of plan and
preventable adverse events on general medicine services.
September 27, 2016
Mueller SK, Schnipper JL, Giannelli K, et al. Impact of regionalized care on concordance of plan and
preventable adverse events on general medicine services. J Hosp Med. 2016;11(9):620-…
-
psnet.ahrq.gov/node/45170/psn-pdf
August 03, 2016 - Radiologist-initiated double reading of abdominal CT:
retrospective analysis of the clinical importance of
changes to radiology reports.
August 3, 2016
Lauritzen PM, Andersen JG, Stokke MV, et al. Radiologist-initiated double reading of abdominal CT:
retrospective analysis of the clinical importance of changes to …
-
psnet.ahrq.gov/node/47308/psn-pdf
December 21, 2018 - Improving pediatric electronic health record usability and
safety through certification: seize the day.
December 21, 2018
Ratwani RM, Moscovitch B, Rising JP. Improving Pediatric Electronic Health Record Usability and Safety
Through Certification: Seize the Day. JAMA Pediatr. 2018;172(11):1007-1008.
doi:10.1001/ja…
-
psnet.ahrq.gov/node/47874/psn-pdf
April 10, 2019 - Evaluating the effect of data standardization and
validation on patient matching accuracy.
April 10, 2019
Grannis SJ, Xu H, Vest JR, et al. Evaluating the effect of data standardization and validation on patient
matching accuracy. J Am Med Inform Assoc. 2019;26(5):447-456. doi:10.1093/jamia/ocy191.
https://psnet.a…
-
psnet.ahrq.gov/node/43336/psn-pdf
July 09, 2014 - Pharmacists in pharmacovigilance: can increased
diagnostic opportunity in community settings translate to
better vigilance?
July 9, 2014
Rutter P, Brown D, Howard J, et al. Pharmacists in pharmacovigilance: can increased diagnostic
opportunity in community settings translate to better vigilance? Drug Saf. 2014;37(…
-
psnet.ahrq.gov/node/50688/psn-pdf
November 20, 2019 - Roles and role ambiguity in patient- and caregiver-
performed outpatient parenteral antimicrobial therapy.
November 20, 2019
Keller SC, Cosgrove SE, Arbaje AI, et al. Roles and Role Ambiguity in Patient- and Caregiver-Performed
Outpatient Parenteral Antimicrobial Therapy. Jt Comm J Qual Patient Saf. 2019;45(11):763…
-
psnet.ahrq.gov/node/47790/psn-pdf
April 08, 2019 - The "hemolyzed" physical examination—situational
challenges to accurate bedside diagnosis.
April 8, 2019
Sargsyan Z. The "Hemolyzed" Physical Examination-Situational Challenges to Accurate Bedside
Diagnosis. JAMA Intern Med. 2019;179(4):465-466. doi:10.1001/jamainternmed.2018.8753.
https://psnet.ahrq.gov/issue/hem…
-
psnet.ahrq.gov/node/73987/psn-pdf
October 20, 2021 - Impact of clinical decision support therapeutic
interchanges on hospital discharge medication omissions
and duplications.
October 20, 2021
Maxwell E, Amerine J, Carlton G, et al. Impact of clinical decision support therapeutic interchanges on
hospital discharge medication omissions and duplications. Am J Health Sy…
-
psnet.ahrq.gov/node/48011/psn-pdf
May 29, 2019 - Is it time for safeguards in the adoption of robotic
surgery?
May 29, 2019
Sheetz KH, Dimick JB. Is It Time for Safeguards in the Adoption of Robotic Surgery? JAMA.
2019;321(20):1971-1972. doi:10.1001/jama.2019.3736.
https://psnet.ahrq.gov/issue/it-time-safeguards-adoption-robotic-surgery
The FDA recently raised …
-
psnet.ahrq.gov/node/47832/psn-pdf
February 27, 2019 - Another round of the blame game: a paralyzing criminal
indictment that recklessly "overrides" just culture.
February 27, 2019
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
https://psnet.ahrq.gov/issue/another-round-blame-game-paralyzing-criminal-indictment-recklessly-
overrides-just-cultu…