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psnet.ahrq.gov/node/43849/psn-pdf
January 28, 2015 - Advancing the science of measurement of diagnostic
errors in healthcare: the Safer Dx framework.
January 28, 2015
Singh H, Sittig DF. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx
framework. BMJ Qual Saf. 2015;24(2):103-110. doi:10.1136/bmjqs-2014-003675.
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psnet.ahrq.gov/node/41393/psn-pdf
June 06, 2012 - Prescribers' interactions with medication alerts at the
point of prescribing: a multi-method, in situ investigation
of the human–computer interaction.
June 6, 2012
Russ AL, Zillich AJ, McManus S, et al. Prescribers' interactions with medication alerts at the point of
prescribing: A multi-method, in situ investigat…
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psnet.ahrq.gov/node/46062/psn-pdf
December 19, 2017 - Frequency and nature of medication errors and adverse
drug events in mental health hospitals: a systematic
review.
December 19, 2017
Alshehri GH, Keers RN, Ashcroft DM. Frequency and nature of medication errors and adverse drug events
in mental health hospitals: a systematic review. Drug Saf. 2017;40(10):871-886. …
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psnet.ahrq.gov/node/72735/psn-pdf
February 10, 2021 - Deficiencies in Inpatient Mental Health Care Coordination
and Processes Prior to a Patient's Death by Suicide, Harry
S. Truman Memorial Veterans' Hospital in Columbia,
Missouri.
February 10, 2021
Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 5, 2021. Report No.
20-01521-48. …
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psnet.ahrq.gov/node/47154/psn-pdf
May 23, 2018 - Comparison of military and civilian methods for
determining potentially preventable deaths: a systematic
review.
May 23, 2018
Janak JC, Sosnov JA, Bares JM, et al. Comparison of Military and Civilian Methods for Determining
Potentially Preventable Deaths: A Systematic Review. JAMA Surg. 2018;153(4):367-375.
doi:1…
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psnet.ahrq.gov/node/74729/psn-pdf
February 02, 2022 - Healing our own: a randomized trial to assess benefits of
peer support.
February 2, 2022
Rivera-Chiauzzi EY, Smith HA, Moore-Murray T, et al. Healing our own: a randomized trial to assess
benefits of peer support. J Patient Saf. 2022;18(1):e308-e314. doi:10.1097/pts.0000000000000771.
https://psnet.ahrq.gov/issue/h…
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psnet.ahrq.gov/node/43143/psn-pdf
April 25, 2016 - Surgical programs in the Veterans Health Administration
maintain briefing and debriefing following medical team
training.
April 25, 2016
West P, Neily J, Warner L, et al. Surgical programs in the Veterans Health Administration maintain briefing
and debriefing following medical team training. Jt Comm J Qual Patient…
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psnet.ahrq.gov/node/72606/psn-pdf
December 23, 2020 - Best Practices in Developing Proprietary Names for
Human Prescription Drug Products Guidance for Industry.
December 23, 2020
Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for
Drug Evaluation and Research; December 2020.
https://psnet.ahrq.gov/issue/best-practices-d…
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psnet.ahrq.gov/node/42264/psn-pdf
May 25, 2022 - Safety Considerations for Container Labels and Carton
Labeling Design to Minimize Medication Errors: Guidance
for Industry.
May 25, 2022
Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for
Drug Evaluation and Research; May 18, 2022.
https://psnet.ahrq.gov/issue/safe…
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psnet.ahrq.gov/node/43932/psn-pdf
March 04, 2015 - Safety considerations to mitigate the risks of
misconnections with small-bore connectors intended for
enteral applications.
March 4, 2015
Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; February
11, 2015.
https://psnet.ahrq.gov/issue/safety-considerations-mitigate-risks…
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psnet.ahrq.gov/node/840144/psn-pdf
November 16, 2022 - Dedicated teams to optimize quality and safety of
surgery: a systematic review.
November 16, 2022
Lentz CM, De Lind Van Wijngaarden RAF, Willeboordse F, et al. Dedicated teams to optimize quality and
safety of surgery: a systematic review. Int J Qual Health Care. 2022;34(4):mzac078.
doi:10.1093/intqhc/mzac078.
ht…
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psnet.ahrq.gov/node/44458/psn-pdf
September 09, 2015 - Utilizing pharmacy students in transitions-of-care
services.
September 9, 2015
L'Hommedieu T, DeCoske M, Lababidi RE, et al. Utilizing pharmacy students in transitions-of-care
services. Am J Health Syst Pharm. 2015;72(15):1266-8. doi:10.2146/ajhp140561.
https://psnet.ahrq.gov/issue/utilizing-pharmacy-students-tran…
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psnet.ahrq.gov/node/37631/psn-pdf
May 18, 2015 - The science of improvement.
May 18, 2015
Berwick DM. The science of improvement. JAMA. 2008;299(10):1182-4. doi:10.1001/jama.299.10.1182.
https://psnet.ahrq.gov/issue/science-improvement
This commentary by Dr. Donald Berwick, president of the Institute for Healthcare Improvement, addresses
the growing tension betw…
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psnet.ahrq.gov/node/36888/psn-pdf
November 30, 2016 - Hospital Survey on Patient Safety Culture: 2007
Comparative Database Report.
November 30, 2016
Sorra J, Nieva V, Famolaro T, et al. Rockville, MD: Agency for Healthcare; 2007. AHRQ publication, no. 07-
0025.
https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2007-comparative-database-report
A key…
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psnet.ahrq.gov/node/73417/psn-pdf
June 23, 2021 - Classification of failures in the perception of
conversational agents (CAs) and their implications on
patient safety.
June 23, 2021
Aftab H, Shah SHH, Habli I. Classification of failures in the perception of conversational agents (CAs) and
their implications on patient safety. Stud Health Technol Inform. 2021;281:…
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psnet.ahrq.gov/node/45124/psn-pdf
June 22, 2016 - The impact of surgical safety checklists on theatre
departments: a critical review of the literature.
June 22, 2016
Cadman V. The impact of surgical safety checklists on theatre departments: a critical review of the
literature. J Perioper Pract. 2016;26(4):62-71.
https://psnet.ahrq.gov/issue/impact-surgical-safety…
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psnet.ahrq.gov/node/73701/psn-pdf
September 15, 2021 - Simulation-based education enhances patient safety
behaviors during central venous catheter placement.
September 15, 2021
Jagneaux T, Caffery TS, Musso MW, et al. Simulation-based education enhances patient safety behaviors
during central venous catheter placement. J Patient Saf. 2021;17(6):425-429.
doi:10.1097/pt…
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psnet.ahrq.gov/node/42862/psn-pdf
January 15, 2014 - VA Health Care: Improvements Needed in Processes
Used to Address Providers' Actions That Contribute to
Adverse Events.
January 15, 2014
Draper D. Washington, DC: United States Government Accountability Office; December 3, 2013.
Publication GAO-14-55.
https://psnet.ahrq.gov/issue/va-health-care-improvements-needed…
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psnet.ahrq.gov/node/45886/psn-pdf
July 05, 2017 - Organizational perspectives of nurse executives in 15
hospitals on the impact and effectiveness of rapid
response teams.
July 5, 2017
Smith PL, McSweeney J. Organizational Perspectives of Nurse Executives in 15 Hospitals on the Impact
and Effectiveness of Rapid Response Teams. Jt Comm J Qual Patient Saf. 2017;43(6…
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psnet.ahrq.gov/node/46760/psn-pdf
January 24, 2018 - Systematic evidence review of rates and burden of harm
of intravenous admixture drug preparation errors in
healthcare settings.
January 24, 2018
Hedlund N, Beer I, Hoppe-Tichy T, et al. Systematic evidence review of rates and burden of harm of
intravenous admixture drug preparation errors in healthcare settings. B…