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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/838083/psn-pdf
September 14, 2022 - A pause in pediatrics: implementation of a pediatric
diagnostic time-out.
September 14, 2022
Yale SC, Cohen SS, Kliegman RM, et al. A pause in pediatrics: implementation of a pediatric diagnostic
time-out. Diagnosis (Berl). 2022;9(3):348-351. doi:10.1515/dx-2022-0010.
https://psnet.ahrq.gov/issue/pause-pediatrics-…
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psnet.ahrq.gov/node/44058/psn-pdf
July 03, 2016 - Metric units and the preferred dosing of orally
administered liquid medications.
July 3, 2016
Metric Units and the Preferred Dosing of Orally Administered Liquid Medications. doi:10.1542/peds.2015-
0072.
https://psnet.ahrq.gov/issue/metric-units-and-preferred-dosing-orally-administered-liquid-medications
Accident…
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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/43249/psn-pdf
June 18, 2014 - Automated and electronically assisted hand hygiene
monitoring systems: a systematic review.
June 18, 2014
Ward MA, Schweizer ML, Polgreen PM, et al. Automated and electronically assisted hand hygiene
monitoring systems: a systematic review. Am J Infect Control. 2014;42(5):472-8.
doi:10.1016/j.ajic.2014.01.002.
ht…
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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/74014/psn-pdf
October 27, 2021 - Adopting system models for multiple incident analysis:
utility and usability.
October 27, 2021
Wheway JL, Jun GT. Adopting systems models for multiple incident analysis: utility and usability. Int J Qual
Health Care. 2021;33(4):mzab135. doi:10.1093/intqhc/mzab135.
https://psnet.ahrq.gov/issue/adopting-system-model…
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psnet.ahrq.gov/node/45135/psn-pdf
September 27, 2017 - Adverse events in robotic surgery: a retrospective study
of 14 years of FDA data.
September 27, 2017
Alemzadeh H, Raman J, Leveson N, et al. Adverse Events in Robotic Surgery: A Retrospective Study of 14
Years of FDA Data. PLoS One. 2016;11(4):e0151470. doi:10.1371/journal.pone.0151470.
https://psnet.ahrq.gov/issu…
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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/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/50556/psn-pdf
January 01, 2021 - The compliance with a patient safety bundle for
management of placenta accreta spectrum.
October 16, 2019
Quist-Nelson J, Crank A, Oliver EA, et al. The compliance with a patient-safety bundle for management of
placenta accreta spectrum†. J Matern Fetal Neonatal Med. 2021;34(17):2880-2886.
doi:10.1080/14767058.201…
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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/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/38907/psn-pdf
January 03, 2017 - Applying Toyota Production System principles to a
psychiatric hospital: making transfers safer and more
timely.
January 3, 2017
Young JQ, Wachter R. Applying Toyota Production System principles to a psychiatric hospital: making
transfers safer and more timely. Jt Comm J Qual Patient Saf. 2009;35(9):439-448.
https…
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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/46831/psn-pdf
April 18, 2018 - Guideline Summary: Medication Safety.
April 18, 2018
Guideline Summary: Medication Safety. AORN J. 2018;107(4):489-494. doi:10.1002/aorn.12096.
https://psnet.ahrq.gov/issue/guideline-summary-medication-safety
Perioperative medication errors can result in patient harm as well as emotional distress among clinical
te…
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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/74763/psn-pdf
June 25, 2021 - FDA Safety Communication: flexible bronchoscopes and
updated recommendations for reprocessing.
June 25, 2021
Silver Springs, MD: US Food and Drug Administration: June 25, 2021.
https://psnet.ahrq.gov/issue/fda-safety-communication-flexible-bronchoscopes-and-updated-
recommendations-reprocessing
Incomplete reproce…
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psnet.ahrq.gov/node/846157/psn-pdf
March 15, 2023 - Patient perception of fall risk and fall risk screening
scores.
March 15, 2023
Solares NP, Calero P, Connelly CD. Patient perception of fall risk and fall risk screening scores. J Nurs
Care Qual. 2023;38(2):100-106. doi:10.1097/ncq.0000000000000645.
https://psnet.ahrq.gov/issue/patient-perception-fall-risk-and-fal…
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psnet.ahrq.gov/node/43758/psn-pdf
March 17, 2015 - A patient safety checklist for the cardiac catheterisation
laboratory.
March 17, 2015
Cahill TJ, Clarke SC, Simpson IA, et al. A patient safety checklist for the cardiac catheterisation laboratory.
Heart. 2015;101(2):91-3. doi:10.1136/heartjnl-2014-306927.
https://psnet.ahrq.gov/issue/patient-safety-checklist-card…