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psnet.ahrq.gov/node/35058/psn-pdf
June 22, 2009 - Predicting and preventing adverse drug reactions in the
very old.
June 22, 2009
Merle L, Laroche M-L, Dantoine T, et al. Predicting and preventing adverse drug reactions in the very old.
Drugs Aging. 2005;22(5):375-92.
https://psnet.ahrq.gov/issue/predicting-and-preventing-adverse-drug-reactions-very-old
The auth…
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psnet.ahrq.gov/node/38658/psn-pdf
September 27, 2017 - Development and psychometric testing of a tool to
measure missed nursing care.
September 27, 2017
Kalisch BJ, Williams RA. Development and psychometric testing of a tool to measure missed nursing care.
J Nurs Adm. 2009;39(5):211-9. doi:10.1097/NNA.0b013e3181a23cf5.
https://psnet.ahrq.gov/issue/development-and-psyc…
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psnet.ahrq.gov/node/47594/psn-pdf
March 17, 2023 - Prevention of perioperative medication errors.
March 17, 2023
Nanji K. UpToDate. March 7, 2023.
https://psnet.ahrq.gov/issue/prevention-perioperative-medication-errors
Perioperative adverse drug events are common and understudied. This review examines factors that
contribute to adverse drug events in the surgical …
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psnet.ahrq.gov/node/37930/psn-pdf
July 23, 2008 - Measurement for improvement: a survey of current
practice in Australian public hospitals.
July 23, 2008
Brand CA, Tropea J, Ibrahim JE, et al. Measurement for improvement: a survey of current practice in
Australian public hospitals. Med J Aust. 2008;189(1):35-40.
https://psnet.ahrq.gov/issue/measurement-improvemen…
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psnet.ahrq.gov/node/35120/psn-pdf
November 03, 2015 - Clinical impact associated with corrected results in
clinical microbiology testing.
November 3, 2015
Yuan S, Astion ML, Schapiro J, et al. Clinical impact associated with corrected results in clinical
microbiology testing. J Clin Microbiol. 2005;43(5):2188-93.
https://psnet.ahrq.gov/issue/clinical-impact-associate…
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psnet.ahrq.gov/node/50720/psn-pdf
December 04, 2019 - Flu shot mix-up at Oklahoma facility leaves 10
hospitalized
December 4, 2019
The Associated Press. NBC News. November 8, 2019.
https://psnet.ahrq.gov/issue/flu-shot-mix-oklahoma-facility-leaves-10-hospitalized
Patients at residential care facilities are particularly vulnerable to harm from medication errors. This …
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psnet.ahrq.gov/print/pdf/node/848754
January 01, 2025 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Implementation of Patient Safety Projects
Curated Library
Foundations
Leading change: why transformation efforts fail.
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
Kotter, a professor at Harvard Business School, outlines the eight stages …
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psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy
November 25, 2020 - The initial physician evaluating the patient was an intern on their first day of service in a busy Emergency
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psnet.ahrq.gov/issue/missed-lesions-abdominal-oncologic-ct-lessons-learned-quality-assurance
April 21, 2011 - Study
Missed lesions at abdominal oncologic CT: lessons learned from quality assurance.
Citation Text:
Siewert B, Sosna J, McNamara A, et al. Missed lesions at abdominal oncologic CT: lessons learned from quality assurance. Radiographics. 2008;28(3):623-38. doi:10.1148/rg.283075188.
…
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psnet.ahrq.gov/issue/long-term-reduction-adverse-drug-events-evidence-based-improvement-model
August 28, 2024 - Study
Long-term reduction in adverse drug events: an evidence-based improvement model.
Citation Text:
Gazarian M, Graudins LV. Long-term reduction in adverse drug events: an evidence-based improvement model. Pediatrics. 2012;129(5):e1334-42. doi:10.1542/peds.2011-1902.
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psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-outputs-are-they-valid
November 25, 2009 - Study
Failure mode and effects analysis outputs: are they valid?
Citation Text:
Shebl NA, Franklin BD, Barber N. Failure mode and effects analysis outputs: are they valid? BMC Health Serv Res. 2012;12:150. doi:10.1186/1472-6963-12-150.
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Format:
DOI Google Scho…
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psnet.ahrq.gov/issue/perspectives-patient-and-family-engagement-reduction-harm-forgotten-voice
December 01, 2011 - Study
Perspectives on patient and family engagement with reduction in harm: the forgotten voice.
Citation Text:
Schenk EC, Bryant RA, Van Son CR, et al. Perspectives on Patient and Family Engagement With Reduction in Harm: The Forgotten Voice. J Nurs Care Qual. 2019;34(1):73-79. doi:10.1…
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psnet.ahrq.gov/issue/improving-medication-related-safety-residents-nursing-homes-qualitative-study
March 24, 2019 - Study
Improving medication-related safety for residents in nursing homes: a qualitative study.
Citation Text:
Shieu B, Lee Y-W, Epps F, et al. Improving medication-related safety for residents in nursing homes: a qualitative study. J Gerontol Nurs. 2025;51(3):38-43. doi:10.3928/00989134-…
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psnet.ahrq.gov/issue/ahrq-psnet-annual-webinar-evidence-advancing-rapid-response-systems-and-opioid-stewardship
December 10, 2024 - Webinar
AHRQ PSNet Annual Webinar: Evidence on Advancing Rapid Response Systems and Opioid Stewardship.
Citation Text:
Agency for Healthcare Quality and Research. AHRQ PSNet Annual Webinar: Evidence on Advancing Rapid Response Systems and Opioid Stewardship. February 10, 2025, 1:00pm-2:0…
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psnet.ahrq.gov/issue/teaching-nursing-students-ethical-and-legal-consequences-medical-errors-insights-radonda
July 05, 2017 - Study
Teaching nursing students the ethical and legal consequences of medical errors: insights from the RaDonda Vaught case using the jigsaw technique.
Citation Text:
Geiselman EL, Opsahl A, Townsend C. Teaching nursing students the ethical and legal consequences of medical errors: insig…
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psnet.ahrq.gov/issue/interventions-improve-timely-cancer-diagnosis-integrative-review
May 25, 2022 - Study
Interventions to improve timely cancer diagnosis: an integrative review.
Citation Text:
Graber ML, Winters BD, Matin R, et al. Interventions to improve timely cancer diagnosis: an integrative review. Diagnosis (Berl). 2024;Epub Oct 18. doi:10.1515/dx-2024-0113.
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psnet.ahrq.gov/issue/special-issue-health-information-technology
August 22, 2007 - June 29, 2022
Scoping review of studies evaluating frailty and its association with medication
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psnet.ahrq.gov/issue/digital-healthcare-research
December 24, 2008 - August 19, 2020
Novel, High-Impact Studies Evaluating Health System and Healthcare Professional
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psnet.ahrq.gov/issue/grants-line-database-gold
December 24, 2008 - September 22, 2021
Novel, High-Impact Studies Evaluating Health System and Healthcare
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psnet.ahrq.gov/issue/hospital-mistakes-kept-secret
September 30, 2009 - June 21, 2017
Medication safety at the interface: evaluating risks associated with discharge