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psnet.ahrq.gov/node/43931/psn-pdf
March 04, 2015 - Design of endoscopic retrograde
cholangiopancreatography (ERCP) duodenoscopes may
impede effective cleaning.
March 4, 2015
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 23, 2015.
https://psnet.ahrq.gov/issue/design-endoscopic-retrograde-cholangiopancreatography-ercp-
duode…
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psnet.ahrq.gov/node/46760/psn-pdf
January 24, 2018 - Systematic evidence review of rates and burden of harm
of intravenous admixture drug preparation errors in
healthcare settings.
January 24, 2018
Hedlund N, Beer I, Hoppe-Tichy T, et al. Systematic evidence review of rates and burden of harm of
intravenous admixture drug preparation errors in healthcare settings. B…
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psnet.ahrq.gov/node/43625/psn-pdf
October 29, 2014 - Assessing distractors and teamwork during surgery:
developing an event-based method for direct observation.
October 29, 2014
Seelandt JC, Tschan F, Keller S, et al. Assessing distractors and teamwork during surgery: developing an
event-based method for direct observation. BMJ Qual Saf. 2014;23(11):918-29. doi:10.11…
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psnet.ahrq.gov/node/845657/psn-pdf
March 08, 2023 - Dissemination and Implementation of Equity-Focused
Evidence-Based Interventions in Healthcare Delivery
Systems (R18).
March 8, 2023
Rockville, MD: Agency for Healthcare Research and Quality. February 15, 2023. RFA-HS-23-002.
https://psnet.ahrq.gov/issue/dissemination-and-implementation-equity-focused-evidence-base…
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psnet.ahrq.gov/node/851652/psn-pdf
July 26, 2023 - Breast cancer missed at screening; hindsight or
mistakes?
July 26, 2023
Hovda T, Larsen M, Romundstad L, et al. Breast cancer missed at screening; hindsight or mistakes? Eur J
Radiol. 2023;165:110913. doi:10.1016/j.ejrad.2023.110913.
https://psnet.ahrq.gov/issue/breast-cancer-missed-screening-hindsight-or-mistakes…
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psnet.ahrq.gov/node/72606/psn-pdf
December 23, 2020 - Best Practices in Developing Proprietary Names for
Human Prescription Drug Products Guidance for Industry.
December 23, 2020
Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for
Drug Evaluation and Research; December 2020.
https://psnet.ahrq.gov/issue/best-practices-d…
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psnet.ahrq.gov/node/836757/psn-pdf
March 16, 2022 - Improving communication and teamwork during labor: a
feasibility, acceptability, and safety study.
March 16, 2022
Weiseth A, Plough A, Aggarwal R, et al. Improving communication and teamwork during labor: A feasibility,
acceptability, and safety study. Birth. 2022;49(4):637-647. doi:10.1111/birt.12630.
https://psn…
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psnet.ahrq.gov/node/865419/psn-pdf
March 27, 2024 - Do Not Miss Sepsis Needles in Viral Haystacks!
March 27, 2024
Hamline M, Shaikh U. Do Not Miss Sepsis Needles in Viral Haystacks!. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accredit…
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - SPOTLIGHT CASE
A Stroke of Error
Citation Text:
Barrett KM. A Stroke of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
January 29, 2021 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon
Citation Text:
Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery
Citation Text:
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/node/862984/psn-pdf
February 21, 2024 - Machine learning in medication prescription: a systematic
review.
February 21, 2024
Iancu A, Leb I, Prokosch H-U, et al. Machine learning in medication prescription: a systematic review. Int J
Med Inform. 2023;180:105241. doi:10.1016/j.ijmedinf.2023.105241.
https://psnet.ahrq.gov/issue/machine-learning-medication-…
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psnet.ahrq.gov/node/44867/psn-pdf
March 23, 2016 - Understanding why quality initiatives succeed or fail: a
sociotechnical systems perspective.
March 23, 2016
Wiegmann DA. Understanding Why Quality Initiatives Succeed or Fail: A Sociotechnical Systems
Perspective. Ann Surg. 2016;263(1):9-11. doi:10.1097/SLA.0000000000001333.
https://psnet.ahrq.gov/issue/understand…
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psnet.ahrq.gov/node/867529/psn-pdf
January 15, 2025 - “I had no idea this happened”: electronic feedback on
clinical reasoning for hospitalists.
January 15, 2025
Kotwal S, Udayappan KM, Kutheala N, et al. “I had no idea this happened”: electronic feedback on clinical
reasoning for hospitalists. J Gen Intern Med. 2024;39(16):3271-3277. doi:10.1007/s11606-024-09058-1.
…
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psnet.ahrq.gov/node/42627/psn-pdf
October 02, 2013 - How much diagnostic safety can we afford, and how
should we decide? A health economics perspective.
October 2, 2013
Newman-Toker DE, McDonald KM, Meltzer DO. How much diagnostic safety can we afford, and how
should we decide? A health economics perspective. BMJ Qual Saf. 2013;22(Suppl 2):ii11-ii20.
doi:10.1136/bmj…
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psnet.ahrq.gov/node/60597/psn-pdf
June 17, 2020 - Organisational factors associated with safety climate,
patient satisfaction and self-reported medicines
adherence in community pharmacies.
June 17, 2020
Jacobs S, Hann M, Bradley F, et al. Organisational factors associated with safety climate, patient
satisfaction and self-reported medicines adherence in community…
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psnet.ahrq.gov/node/845300/psn-pdf
March 01, 2023 - The impact of medication reconciliation and review in
patients using oral chemotherapy.
March 1, 2023
Darcis E, Germeys J, Stragier M, et al. The impact of medication reconciliation and review in patients using
oral chemotherapy. J Oncol Pharm Pract. 2023;29(2):270-275. doi:10.1177/10781552211066959.
https://psnet…
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psnet.ahrq.gov/node/837501/psn-pdf
June 22, 2022 - Development and validation of a brief culture-of-safety
survey.
June 22, 2022
Barnard C, Chung JW, Flaherty V, et al. Development and validation of a brief culture-of-safety survey. Jt
Comm J Qual Patient Saf. 2022;48(9):430-438. doi:10.1016/j.jcjq.2022.04.006.
https://psnet.ahrq.gov/issue/development-and-validati…
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psnet.ahrq.gov/node/45626/psn-pdf
October 29, 2017 - The impacts of a pharmacist-managed outpatient clinic
and chemotherapy-directed electronic order sets for
monitoring oral chemotherapy.
October 29, 2017
Battis B, Clifford L, Huq M, et al. The impacts of a pharmacist-managed outpatient clinic and
chemotherapy-directed electronic order sets for monitoring oral chem…
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psnet.ahrq.gov/node/853974/psn-pdf
January 01, 2024 - Barriers and facilitators associated with the
implementation of surgical safety checklists: a qualitative
systematic review.
September 27, 2023
Paterson C, Mckie A, Turner M, et al. Barriers and facilitators associated with the implementation of
surgical safety checklists: a qualitative systematic review. J Adv Nu…