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psnet.ahrq.gov/node/38904/psn-pdf
September 02, 2009 - Litigation related to inadequate anaesthesia: an analysis
of claims against the NHS in England 1995-2007.
September 2, 2009
Mihai R, Scott SD, Cook TM. Litigation related to inadequate anaesthesia: an analysis of claims against the
NHS in England 1995-2007. Anaesthesia. 2009;64(8):829-35. doi:10.1111/j.1365-2044.20…
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psnet.ahrq.gov/node/37135/psn-pdf
October 04, 2011 - Combining ratings from multiple physician reviewers
helped to overcome the uncertainty associated with
adverse event classification.
October 4, 2011
Forster AJ, O'Rourke K, Shojania KG, et al. Combining ratings from multiple physician reviewers helped to
overcome the uncertainty associated with adverse event class…
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psnet.ahrq.gov/node/40002/psn-pdf
January 19, 2011 - Considerations for the design of safe and effective
consumer health IT applications in the home.
January 19, 2011
Zayas-Cabán T, Dixon BE. Considerations for the design of safe and effective consumer health IT
applications in the home. Qual Saf Health Care. 2010;19 Suppl 3:i61-i67. doi:10.1136/qshc.2010.041897.
ht…
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psnet.ahrq.gov/node/37098/psn-pdf
October 04, 2011 - How residents think and make medical decisions:
implications for education and patient safety.
October 4, 2011
Young JS, Smith RL, Guerlain S, et al. How residents think and make medical decisions: implications for
education and patient safety. Am Surg. 2007;73(6):548-553; discussion 553-4.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/43512/psn-pdf
September 29, 2017 - Interruptions and multi-tasking: moving the research
agenda in new directions.
September 29, 2017
Westbrook JI. Interruptions and multi-tasking: moving the research agenda in new directions. BMJ Qual
Saf. 2014;23(11):877-9. doi:10.1136/bmjqs-2014-003372.
https://psnet.ahrq.gov/issue/interruptions-and-multi-tasking…
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psnet.ahrq.gov/node/40237/psn-pdf
February 23, 2011 - The impact of the medical emergency team on the
resuscitation practice of critical care nurses.
February 23, 2011
Santiano N, Young L, Baramy LS, et al. The impact of the medical emergency team on the resuscitation
practice of critical care nurses. BMJ Qual Saf. 2011;20(2):115-20. doi:10.1136/bmjqs.2008.029876.
ht…
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psnet.ahrq.gov/node/73498/psn-pdf
July 14, 2021 - Leaving a discontinued FentaNYL infusion attached to the
patient leads to a tragic error
July 14, 2021
ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2.
https://psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error
High-alert medication misadministration i…
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psnet.ahrq.gov/node/45619/psn-pdf
August 16, 2017 - Checking the lists: a systematic review of electronic
checklist use in health care.
August 16, 2017
Kramer HS, Drews FA. Checking the lists: A systematic review of electronic checklist use in health care. J
Biomed Inform. 2017;71S:S6-S12. doi:10.1016/j.jbi.2016.09.006.
https://psnet.ahrq.gov/issue/checking-lists-s…
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psnet.ahrq.gov/node/34870/psn-pdf
April 18, 2016 - Unintended medication discrepancies at the time of
hospital admission.
April 18, 2016
Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital
admission. Arch Intern Med. 2005;165(4):424-9.
https://psnet.ahrq.gov/issue/unintended-medication-discrepancies-time-hospita…
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psnet.ahrq.gov/node/865682/psn-pdf
April 24, 2024 - Global Medical Supply Chain Security.
April 24, 2024
Cadwallader AB, ed. AMA J Ethics. 2024;26(4):e275-e359.
https://psnet.ahrq.gov/issue/global-medical-supply-chain-security
Drug shortages are a known problem that gained patient safety prominence during the COVID-19
pandemic. This special issue covers a rang…
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psnet.ahrq.gov/node/42660/psn-pdf
October 16, 2013 - Practice indicators of suboptimal care and avoidable
adverse events: a content analysis of a national qualifying
examination.
October 16, 2013
Bordage G, Meguerditchian A-N, Tamblyn R. Practice indicators of suboptimal care and avoidable adverse
events: a content analysis of a national qualifying examination. Acad…
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psnet.ahrq.gov/node/44227/psn-pdf
November 19, 2018 - A scholarly pathway in quality improvement and patient
safety.
November 19, 2018
Ferguson CC, Lamb G. A Scholarly Pathway in Quality Improvement and Patient Safety. Acad Med.
2015;90(10):1358-62. doi:10.1097/ACM.0000000000000772.
https://psnet.ahrq.gov/issue/scholarly-pathway-quality-improvement-and-patient-safety…
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psnet.ahrq.gov/node/39838/psn-pdf
September 15, 2010 - A multicenter trial of aviation-style training for surgical
teams.
September 15, 2010
Catchpole K, Dale TJ, Hirst G, et al. A multicenter trial of aviation-style training for surgical teams. J Patient
Saf. 2010;6(3):180-6. doi:10.1097/PTS.0b013e3181f100ea.
https://psnet.ahrq.gov/issue/multicenter-trial-aviation-st…
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psnet.ahrq.gov/node/42661/psn-pdf
October 16, 2013 - Utility and assessment of non-technical skills for rapid
response systems and medical emergency teams.
October 16, 2013
Chalwin RP, Flabouris A. Utility and assessment of non-technical skills for rapid response systems and
medical emergency teams. Intern Med J. 2013;43(9):962-9. doi:10.1111/imj.12172.
https://psne…
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psnet.ahrq.gov/node/74850/psn-pdf
February 16, 2022 - Medicare penalizes dozens of hospitals it also gives five
stars.
February 16, 2022
Rau J. Kaiser Health News. February 8, 2022.
https://psnet.ahrq.gov/issue/medicare-penalizes-dozens-hospitals-it-also-gives-five-stars
Rating systems face challenges to accurately represent the safety and quality of patient ca…
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psnet.ahrq.gov/node/866823/psn-pdf
September 25, 2024 - Understanding human factors in patient safety when
prescribing.
September 25, 2024
Coon R, Holden K. Understanding human factors in patient safety when prescribing. Pharmaceutical
Journal. September 2024;313(7989).
https://psnet.ahrq.gov/issue/understanding-human-factors-patient-safety-when-prescribing
Prescripti…
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psnet.ahrq.gov/node/854634/psn-pdf
January 01, 2024 - Elopement: evidence-based mitigation and management.
October 18, 2023
Marlett JE, Vacovsky BA, Krug EA, et al. Elopement: evidence?based mitigation and management.
Worldviews Evid Based Nurs. 2024;20(6):634-641. doi:10.1111/wvn.12683.
https://psnet.ahrq.gov/issue/elopement-evidence-based-mitigation-and-management
…
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psnet.ahrq.gov/node/46837/psn-pdf
March 21, 2018 - Drug shortages: effect on parenteral nutrition therapy.
March 21, 2018
Holcombe B, Mattox TW, Plogsted S. Drug Shortages: Effect on Parenteral Nutrition Therapy. Nutr Clin
Pract. 2018;33(1):53-61. doi:10.1002/ncp.10052.
https://psnet.ahrq.gov/issue/drug-shortages-effect-parenteral-nutrition-therapy
Shortages of me…
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psnet.ahrq.gov/node/48001/psn-pdf
May 22, 2019 - Medicines safety in anaesthetic practice.
May 22, 2019
Mackay E, Jennings J, Webber S. Medicines safety in anaesthetic practice. BJA Edu. 2019;19(5):151-157.
doi:10.1016/j.bjae.2019.01.001.
https://psnet.ahrq.gov/issue/medicines-safety-anaesthetic-practice
Human factors affect medication delivery in the operating …
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psnet.ahrq.gov/node/41205/psn-pdf
June 15, 2012 - Quality assessment of spontaneous triggered adverse
event reports received by the Food and Drug
Administration.
June 15, 2012
Brajovic S, Piazza-Hepp T, Swartz L, et al. Quality assessment of spontaneous triggered adverse event
reports received by the Food and Drug Administration. Pharmacoepidemiol Drug Saf. 2012;…