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psnet.ahrq.gov/node/43307/psn-pdf
September 26, 2016 - Mitigating errors caused by interruptions during
medication verification and administration: interventions
in a simulated ambulatory chemotherapy setting.
September 26, 2016
Prakash V, Koczmara C, Savage P, et al. Mitigating errors caused by interruptions during medication
verification and administration: interven…
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psnet.ahrq.gov/node/47681/psn-pdf
January 30, 2019 - Infection prevention in the operating room anesthesia
work area.
January 30, 2019
Munoz-Price S, Bowdle A, Johnston L, et al. Infection prevention in the operating room anesthesia work
area. Infect Control Hosp Epidemiol. 2018:1-17. doi:10.1017/ice.2018.303.
https://psnet.ahrq.gov/issue/infection-prevention-operat…
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psnet.ahrq.gov/node/50557/psn-pdf
October 16, 2019 - Effect of an Electronic Medication Reconciliation
Intervention on Adverse Drug Events: A Cluster
Randomized Trial
October 16, 2019
Tamblyn R, Abrahamowicz M, Buckeridge DL, et al. Effect of an Electronic Medication Reconciliation
Intervention on Adverse Drug Events: A Cluster Randomized Trial. JAMA Netw Open. 2019…
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psnet.ahrq.gov/node/44554/psn-pdf
November 20, 2015 - Hospice diagnosis: polypharmacy—a teachable moment.
November 20, 2015
Larson CK, Kao H. Hospice Diagnosis: Polypharmacy: A Teachable Moment. JAMA Intern Med.
2015;175(11):1750-1751. doi:10.1001/jamainternmed.2015.5253.
https://psnet.ahrq.gov/issue/hospice-diagnosis-polypharmacy-teachable-moment
Overprescribing can…
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psnet.ahrq.gov/node/46650/psn-pdf
July 12, 2018 - Towards a more patient-centered approach to medication
safety.
July 12, 2018
Lee JL, Dy SM, Gurses AP, et al. Towards a More Patient-Centered Approach to Medication Safety. J
Patient Exp. 2018;5(2):83-87. doi:10.1177/2374373517727532.
https://psnet.ahrq.gov/issue/towards-more-patient-centered-approach-medication-s…
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psnet.ahrq.gov/node/44365/psn-pdf
November 20, 2015 - A prospective study of suicide screening tools and their
association with near-term adverse events in the ED.
November 20, 2015
Chang BP, Tan TM. Suicide screening tools and their association with near-term adverse events in the ED.
Am J Emerg Med. 2015;33(11):1680-1683. doi:10.1016/j.ajem.2015.08.013.
https://psn…
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psnet.ahrq.gov/node/39517/psn-pdf
May 25, 2010 - A prospective controlled trial of the effect of a multi-
faceted intervention on early recognition and intervention
in deteriorating hospital patients.
May 25, 2010
Mitchell IA, McKay H, Van Leuvan C, et al. A prospective controlled trial of the effect of a multi-faceted
intervention on early recognition and inter…
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psnet.ahrq.gov/node/41191/psn-pdf
March 21, 2012 - Reviewing the impact of computerized provider order
entry on clinical outcomes: the quality of systematic
reviews.
March 21, 2012
Weir C, Staggers N, Laukert T. Reviewing the impact of computerized provider order entry on clinical
outcomes: The quality of systematic reviews. Int J Med Inform. 2012;81(4):219-31.
d…
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psnet.ahrq.gov/node/45094/psn-pdf
May 04, 2016 - Actions Needed to Improve Newly Enrolled Veterans'
Access to Primary Care.
May 4, 2016
Washington, DC: United States Government Accountability Office; March 18, 2016. Publication GAO-16-
328.
https://psnet.ahrq.gov/issue/actions-needed-improve-newly-enrolled-veterans-access-primary-care
This analysis found that s…
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psnet.ahrq.gov/node/46763/psn-pdf
January 27, 2019 - Human-simulation-based learning to prevent medication
error: a systematic review.
January 27, 2019
Sarfati L, Ranchon F, Vantard N, et al. Human-simulation-based learning to prevent medication error: A
systematic review. J Eval Clin Pract. 2019;25(1):11-20. doi:10.1111/jep.12883.
https://psnet.ahrq.gov/issue/human…
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psnet.ahrq.gov/node/867049/psn-pdf
October 30, 2024 - National Review of Maternity Services in England 2022 to
2024.
October 30, 2024
National Review Of Maternity Services In England 2022 To 2024. Newcastle Upon Tyne, UK: Care Quality
Commission; September 2024.
https://psnet.ahrq.gov/issue/national-review-maternity-services-england-2022-2024
Maternal safety is a gl…
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psnet.ahrq.gov/node/41087/psn-pdf
November 26, 2014 - Use of an appreciative inquiry approach to improve
resident sign-out in an era of multiple shift changes.
November 26, 2014
Helms AS, Perez TE, Baltz J, et al. Use of an appreciative inquiry approach to improve resident sign-out in
an era of multiple shift changes. J Gen Intern Med. 2012;27(3):287-91. doi:10.1007/s…
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psnet.ahrq.gov/node/35182/psn-pdf
April 11, 2011 - Standard drug concentrations and smart-pump
technology reduce continuous-medication-infusion errors
in pediatric patients.
April 11, 2011
Larsen G, Parker HB, Cash J, et al. Standard drug concentrations and smart-pump technology reduce
continuous-medication-infusion errors in pediatric patients. Pediatrics. 2005;1…
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psnet.ahrq.gov/node/44352/psn-pdf
August 12, 2015 - Hospital checklists are meant to save lives—so why do
they often fail?
August 12, 2015
Anthes E. Hospital checklists are meant to save lives - so why do they often fail? Nature.
2015;523(7562):516-8. doi:10.1038/523516a.
https://psnet.ahrq.gov/issue/hospital-checklists-are-meant-save-lives-so-why-do-they-often-fai…
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psnet.ahrq.gov/node/42117/psn-pdf
March 20, 2013 - Nurse–patient ratios as a patient safety strategy: a
systematic review.
March 20, 2013
Shekelle PG. Nurse-patient ratios as a patient safety strategy: a systematic review. Ann Intern Med.
2013;158(5 Pt 2):404-409. doi:10.7326/0003-4819-158-5-201303051-00007.
https://psnet.ahrq.gov/issue/nurse-patient-ratios-patien…
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psnet.ahrq.gov/node/60804/psn-pdf
August 12, 2020 - Improved medication management with introduction of a
perioperative and prescribing pharmacist service.
August 12, 2020
Nguyen AD, Lam A, Banakh I, et al. Improved medication management with introduction of a perioperative
and prescribing pharmacist service. J Pharm Pract. 2020;33(3):299-305. doi:10.1177/0897190018…
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psnet.ahrq.gov/node/34990/psn-pdf
June 22, 2009 - Detecting adverse drug reactions on paediatric wards:
intensified surveillance versus computerised screening of
laboratory values.
June 22, 2009
Haffner S, von Laue N, Wirth S, et al. Detecting adverse drug reactions on paediatric wards: intensified
surveillance versus computerised screening of laboratory values. …
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psnet.ahrq.gov/node/60034/psn-pdf
March 11, 2020 - Responding to unprofessional behavior by trainees - a
"just culture" framework.
March 11, 2020
Wasserman JA, Redinger M, Gibb T. Responding to Unprofessional Behavior by Trainees — A “Just
Culture” Framework. New England Journal of Medicine. 2020;382(8). doi:10.1056/nejmms1912591.
https://psnet.ahrq.gov/issue/resp…
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psnet.ahrq.gov/node/862613/psn-pdf
February 14, 2024 - Standardizing medication reconciliation in a pediatric
emergency department.
February 14, 2024
Sheth S, Bialostozky M, Hollenbach K, et al. Standardizing medication reconciliation in a pediatric
emergency department. Pediatrics. 2024;153(2):e2023061964. doi:10.1542/peds.2023-061964.
https://psnet.ahrq.gov/issue/st…
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psnet.ahrq.gov/node/40308/psn-pdf
April 22, 2011 - Improving patient safety: the comparative views of
patient-safety specialists, workforce staff and managers.
April 22, 2011
Braithwaite J, Westbrook MT, Robinson M, et al. Improving patient safety: the comparative views of patient-
safety specialists, workforce staff and managers. BMJ Qual Saf. 2011;20(5):424-31.
…