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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/44057/psn-pdf
June 03, 2015 - Measuring nursing error: psychometrics of MISSCARE
and practice and professional issues items.
June 3, 2015
Castner J, Dean-Baar S. Measuring nursing error: psychometrics of MISSCARE and practice and
professional issues items. J Nurs Manag. 2014;22(3):421-437.
https://psnet.ahrq.gov/issue/measuring-nursing-error-p…
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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/35749/psn-pdf
May 09, 2014 - Chemotherapy dose limits set by users of a computer
order entry system.
May 9, 2014
DuBeshter B; Griggs J; Angel C; Loughner J.
https://psnet.ahrq.gov/issue/chemotherapy-dose-limits-set-users-computer-order-entry-system
To avoid excessive dosing of chemotherapeutic agents, standardized dose limits must be agreed u…
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psnet.ahrq.gov/node/47135/psn-pdf
July 25, 2018 - Structured patient handoff on an internal medicine ward:
a cluster randomized control trial.
July 25, 2018
Tam P, Nijjar AP, Fok M, et al. Structured patient handoff on an internal medicine ward: A cluster
randomized control trial. PLoS One. 2018;13(4):e0195216. doi:10.1371/journal.pone.0195216.
https://psnet.ahrq…
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psnet.ahrq.gov/node/35176/psn-pdf
June 23, 2009 - Mapping changes in surgical mortality over 9 years by
peer review audit.
June 23, 2009
Thompson A, Ashraf Z, Burton H, et al. Mapping changes in surgical mortality over 9 years by peer review
audit. Br J Surg. 2005;92(11):1449-52.
https://psnet.ahrq.gov/issue/mapping-changes-surgical-mortality-over-9-years-peer-re…
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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/39407/psn-pdf
March 31, 2010 - What ring tone should be used for patient safety? Early
results with a Blackberry-based telementoring safety
solution.
March 31, 2010
Parker A, Rubinfeld IS, Azuh O, et al. What ring tone should be used for patient safety? Early results with a
Blackberry-based telementoring safety solution. Am J Surg. 2010;199(3):…
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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
…