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psnet.ahrq.gov/node/841472/psn-pdf
December 14, 2022 - Reducing potential errors associated with insulin
administration: an integrative review.
December 14, 2022
Alqahtani N. Reducing potential errors associated with insulin administration: an integrative review. J Eval
Clin Pract. 2022;28(6):1037-1049. doi:10.1111/jep.13668.
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psnet.ahrq.gov/node/44245/psn-pdf
July 15, 2015 - Patient-initiated second opinions: systematic review of
characteristics and impact on diagnosis, treatment, and
satisfaction.
July 15, 2015
Payne VL, Singh H, Meyer AND, et al. Patient-Initiated Second Opinions: Systematic Review of
Characteristics and Impact on Diagnosis, Treatment, and Satisfaction. Mayo Clinic …
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psnet.ahrq.gov/node/38347/psn-pdf
May 24, 2015 - Using Telehealth to Improve Quality and Safety: Findings
from the AHRQ Portfolio.
May 24, 2015
Dixon BE, Hook JM, McGowan JJ, for AHRQ National Resource Center for Health IT. Rockville, MD:
Agency for Healthcare Research and Quality; December 2008. AHRQ Publication No. 09-0012-EF.
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psnet.ahrq.gov/node/60981/psn-pdf
October 07, 2020 - Unintended consequences of health care reform: impact
of changes in payor mix on patient safety indicators,
October 7, 2020
Bartholomew AJ, Zeymo A, Chan KS, et al. Unintended consequences of health care reform: impact of
changes in payor mix on patient safety indicators,. Ann Surg. 2020;272(4):612-619.
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January 24, 2024 - Clinical deterioration as a nurse sensitive indicator in the
out-of-hospital context: a scoping review.
January 24, 2024
Mccullough K, Baker M, Bloxsome D, et al. Clinical deterioration as a nurse sensitive indicator in the out?of
?hospital context: a scoping review. J Clin Nurs. 2024;33(3):874-889. doi:10.1111/joc…
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psnet.ahrq.gov/node/46858/psn-pdf
May 11, 2019 - Evidence review conducted for the Agency for Healthcare
Research and Quality Safety Program for Improving
Surgical Care and Recovery: focus on anesthesiology for
colorectal surgery.
May 11, 2019
Ban KA, Gibbons MM, Ko CY, et al. Evidence Review Conducted for the Agency for Healthcare Research
and Quality Safety …
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psnet.ahrq.gov/node/47015/psn-pdf
May 09, 2018 - How DeKalb Medical fixed drug safety problems after fatal
error.
May 9, 2018
Porter S. HealthLeaders Media. April 26, 2018.
https://psnet.ahrq.gov/issue/how-dekalb-medical-fixed-drug-safety-problems-after-fatal-error
Overreliance on technology can result in harmful medication mistakes. Reporting on a 10-fold medic…
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December 07, 2016 - Global patient outcomes after elective surgery:
prospective cohort study in 27 low-, middle- and high-
income countries.
December 7, 2016
group ISOS. Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle-
and high-income countries. Br J Anaesth. 2016;117(5):601-609. doi:10.109…
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psnet.ahrq.gov/node/836810/psn-pdf
March 30, 2022 - Periodic resuscitation cart checks and nurse situational
awareness: an observational study.
March 30, 2022
Aljuaid J, Al-Moteri M. Periodic resuscitation cart checks and nurse situational awareness: an observational
study. J Emerg Nurs. 2022;48(2):189-201. doi:10.1016/j.jen.2021.12.002.
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psnet.ahrq.gov/node/43780/psn-pdf
September 09, 2015 - Rapid response systems and collective (in)competence:
an exploratory analysis of intraprofessional and
interprofessional activation factors.
September 9, 2015
Kitto S, Marshall SD, McMillan SE, et al. Rapid response systems and collective (in)competence: An
exploratory analysis of intraprofessional and interprofes…
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psnet.ahrq.gov/node/73675/psn-pdf
September 08, 2021 - A system-wide hospital child maltreatment patient safety
program.
September 8, 2021
Hansen J, Terreros A, Sherman A, et al. A system-wide hospital child maltreatment patient safety program.
Pediatrics. 2021;148(3):e2021050555. doi:10.1542/peds.2021-050555.
https://psnet.ahrq.gov/issue/system-wide-hospital-child-ma…
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psnet.ahrq.gov/node/866447/psn-pdf
August 07, 2024 - Older adults are often misdiagnosed. Specialized ERs and
trained clinicians can help.
August 7, 2024
Milne-Tyte A. Older adults are often misdiagnosed. Specialized ERs and trained clinicians can help. Health
Shots. National Public Radio. July 30, 2024;
https://psnet.ahrq.gov/issue/older-adults-are-often-misdiagnos…
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psnet.ahrq.gov/node/854635/psn-pdf
January 01, 2024 - CheckPOINT: a simple tool to measure Surgical Safety
Checklist implementation fidelity.
October 18, 2023
Moyal-Smith R, Etheridge JC, Turley N, et al. CheckPOINT: a simple tool to measure Surgical Safety
Checklist implementation fidelity. BMJ Qual Saf. 2024;33(4):223-231. doi:10.1136/bmjqs-2023-016030.
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March 07, 2018 - Learning collaboratives: insights and a new taxonomy
from AHRQ's two decades of experience.
March 7, 2018
Nix M, McNamara P, Genevro J, et al. Learning Collaboratives: Insights And A New Taxonomy From
AHRQ's Two Decades Of Experience. Health Aff (Millwood). 2018;37(2):205-212.
doi:10.1377/hlthaff.2017.1144.
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January 01, 2018 - A prospective risk assessment of informal carers'
medication administration errors within the domiciliary
setting.
December 19, 2017
Parand A, Faiella G, Franklin BD, et al. A prospective risk assessment of informal carers' medication
administration errors within the domiciliary setting. Ergonomics. 2018;61(1):104…
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psnet.ahrq.gov/node/35739/psn-pdf
July 15, 2010 - CT for suspected appendicitis in children: an analysis of
diagnostic errors.
July 15, 2010
Taylor GA, Callahan MJ, Rodriguez D, et al. CT for suspected appendicitis in children: an analysis of
diagnostic errors. Pediatr Radiol. 2006;36(4):331-7.
https://psnet.ahrq.gov/issue/ct-suspected-appendicitis-children-analy…
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September 18, 2019 - Adapting cognitive task analysis to investigate clinical
decision making and medication safety incidents.
September 18, 2019
Russ AL, Militello LG, Glassman PA, et al. Adapting Cognitive Task Analysis to Investigate Clinical
Decision Making and Medication Safety Incidents. J Patient Saf. 2019;15(3):191-197.
doi:10…
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psnet.ahrq.gov/node/848089/psn-pdf
April 26, 2023 - Patient Safety Advisory: fentanyl counterfeit prescription
medications that contain fentanyl and patient safety.
April 26, 2023
Jewell ML, Jewell HL, Singer R, et al. Patient Safety Advisory: fentanyl counterfeit prescription medications
that contain fentanyl and patient safety. Aesthetic Plast Surg. 2023;47(3):123…
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August 09, 2023 - Electronic health record usability contributions to patient
safety and clinician burnout: a path forward.
August 9, 2023
Schwappach DLB, Ratwani RM. Electronic health record usability contributions to patient safety and
clinician burnout: a path forward. J Patient Saf. 2023;19(5):38-39. doi:10.1097/pts.000000000000…
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psnet.ahrq.gov/node/38310/psn-pdf
June 03, 2010 - The relationship between early emergency team calls and
serious adverse events.
June 3, 2010
Chen J, Bellomo R, Flabouris A, et al. The relationship between early emergency team calls and serious
adverse events. Crit Care Med. 2009;37(1):148-53. doi:10.1097/CCM.0b013e3181928ce3.
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