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psnet.ahrq.gov/node/866405/psn-pdf
July 31, 2024 - Analysis of an academic medical center’s corrective
action plan in response to fatal medication error using the
Institute for Safe Medication Practices’ Hierarchy of
Effectiveness.
July 31, 2024
Stolte AR, Siwy YM, Tanios SB, et al. Analysis of an academic medical center’s corrective action plan in
response to fa…
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psnet.ahrq.gov/node/860715/psn-pdf
January 17, 2024 - Development of prescribing indicators related to opioid-
related harm in patients with chronic pain in primary care-
a modified e-Delphi study.
January 17, 2024
Bansal N, Campbell SM, Lin C-Y, et al. Development of prescribing indicators related to opioid-related
harm in patients with chronic pain in primary care—…
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psnet.ahrq.gov/node/39581/psn-pdf
January 03, 2017 - An implementation strategy for a multicenter pediatric
rapid response system in Ontario.
January 3, 2017
Buist MD, Shearer W. Rapid Response Systems: A Mandatory System of Care or an Optional Extra for
Bedside Clinical Staff? The Joint Commission Journal on Quality and Patient Safety. 2016;36(6).
doi:10.1016/s1553…
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psnet.ahrq.gov/node/39729/psn-pdf
September 20, 2011 - Contextual errors and failures in individualizing patient
care: a multicenter study.
September 20, 2011
Weiner SJ, Schwartz A, Weaver FM, et al. Contextual errors and failures in individualizing patient care: a
multicenter study. Ann Intern Med. 2010;153(2):69-75. doi:10.7326/0003-4819-153-2-201007200-00002.
https…
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psnet.ahrq.gov/node/38891/psn-pdf
January 04, 2010 - Do calculation errors by nurses cause medication errors
in clinical practice? A literature review.
January 4, 2010
Wright K. Do calculation errors by nurses cause medication errors in clinical practice? A literature review.
Nurse Educ Today. 2010;30(1):85-97. doi:10.1016/j.nedt.2009.06.009.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/37776/psn-pdf
January 31, 2011 - Barcoded medication administration: a last line of
defense.
January 31, 2011
Cescon DW, Etchells E. Barcoded medication administration: a last line of defense. JAMA.
2008;299(18):2200-2. doi:10.1001/jama.299.18.2200.
https://psnet.ahrq.gov/issue/barcoded-medication-administration-last-line-defense
Barcoding techn…
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psnet.ahrq.gov/node/867013/psn-pdf
October 23, 2024 - Reducing automated dispensing cabinet overrides in the
peri-anesthesia care unit: a quality improvement project.
October 23, 2024
Franciscovich CD, Bieniek A, Dunn K, et al. Reducing automated dispensing cabinet overrides in the peri-
anesthesia care unit: a quality improvement project. Jt Comm J Qual Patient Saf. …
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psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-paramedics-provide-home
October 30, 2024 - At the home visits, the APRNs answered questions about medications, corrected medication errors, and evaluated
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psnet.ahrq.gov/node/49733/psn-pdf
May 01, 2015 - She was evaluated
by adult cardiology and cardiac surgery, and she was advised to undergo an aortic
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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - Throughout this case, the patient experienced significant delays in being evaluated.
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psnet.ahrq.gov/perspective/conversation-andrew-bindman-md
June 15, 2024 - What was remarkable about this program, and AHRQ was an early supporter of it and evaluated the work
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psnet.ahrq.gov/issue/computer-alert-system-prevent-injury-adverse-drug-events-development-and-evaluation-community
November 01, 2016 - Study
Classic
A computer alert system to prevent injury from adverse drug events: development and evaluation in a community teaching hospital.
Citation Text:
Raschke RA, Gollihare B, Wunderlich TA, et al. A Computer Alert System to Prevent Injury From Adverse …
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psnet.ahrq.gov/node/36909/psn-pdf
January 05, 2017 - Medical team training: applying crew resource
management in the Veterans Health Administration.
January 5, 2017
Dunn EJ, Mills PD, Neily J, et al. Medical team training: applying crew resource management in the
Veterans Health Administration. Jt Comm J Qual Patient Saf. 2007;33(6):317-325.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/47733/psn-pdf
April 27, 2019 - Impact of the Agency for Healthcare Research and
Quality's Safety Program for Perinatal Care.
April 27, 2019
Kahwati LC, Sorensen A, Teixeira-Poit S, et al. Impact of the Agency for Healthcare Research and
Quality's Safety Program for Perinatal Care. Jt Comm J Qual Patient Saf. 2019;45(4):231-240.
doi:10.1016/j.jc…
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psnet.ahrq.gov/node/45694/psn-pdf
June 15, 2017 - Implementation of the World Health Organization Trauma
Care Checklist Program in 11 centers across multiple
economic strata: effect on care process measures.
June 15, 2017
Lashoher A, Schneider EB, Juillard C, et al. Implementation of the World Health Organization Trauma Care
Checklist Program in 11 Centers Across…
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psnet.ahrq.gov/node/50458/psn-pdf
October 09, 2019 - Success of a resident-led safety council: a model for
satisfying CLER Pathways to Excellence patient safety
goals.
October 9, 2019
Cohen SP, Pelletier JH, Ladd JM, et al. Success of a resident-led safety council: a model for satisfying
CLER Pathways to Excellence patient safety goals. J Gen Intern Med. 2019;11(2):…
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psnet.ahrq.gov/node/40932/psn-pdf
July 05, 2016 - Health IT and Patient Safety: Building Safer Systems for
Better Care.
July 5, 2016
Committee on Patient Safety and Health Information Technology, Board on Health Care Services, Institute
of Medicine. Washington, DC: National Academies Press; 2011. ISBN: 9780309221122.
https://psnet.ahrq.gov/issue/health-it-and-pat…
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psnet.ahrq.gov/node/849595/psn-pdf
May 31, 2023 - Effect of an emergency department process improvement
package on suicide prevention: the ED-SAFE 2 cluster
randomized clinical trial.
May 31, 2023
Boudreaux ED, Larkin C, Vallejo Sefair A, et al. Effect of an emergency department process improvement
package on suicide prevention: the ED-SAFE 2 cluster randomized c…
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psnet.ahrq.gov/node/46904/psn-pdf
August 20, 2018 - Effect of a pediatric early warning system on all-cause
mortality in hospitalized pediatric patients.
August 20, 2018
Parshuram CS, Dryden-Palmer K, Farrell C, et al. Effect of a Pediatric Early Warning System on All-Cause
Mortality in Hospitalized Pediatric Patients: The EPOCH Randomized Clinical Trial. JAMA.
201…
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psnet.ahrq.gov/node/846160/psn-pdf
March 15, 2023 - Critical care teamwork in the future: the role of
TeamSTEPPS in the COVID-19 pandemic and implications
for the future.
March 15, 2023
Terregino CA, Jagpal S, Parikh P, et al. Critical Care Teamwork in the Future: The Role of Critical care
teamwork in the future: the role of TeamSTEPPS in the COVID-19 pandemic and …