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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840170/psn-pdf
    November 16, 2022 - Predicting dispensing errors in community pharmacies: an application of the Systematic Human Error Reduction and Prediction Approach (SHERPA). November 16, 2022 Ashour A, Phipps DL, Ashcroft DM. PLoS ONE. 2022;17(1):e0261672. https://psnet.ahrq.gov/innovation/predicting-dispensing-errors-community-pharmacies-…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39670/psn-pdf
    July 07, 2010 - The Power of Safety: State Reporting Provides Lessons in Reducing Harm, Improving Care. July 7, 2010 Washington DC: National Quality Forum; 2010. https://psnet.ahrq.gov/issue/power-safety-state-reporting-provides-lessons-reducing-harm-improving-care The landmark Institute of Medicine (IOM) report, To Err Is Human,…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34714/psn-pdf
    February 18, 2011 - Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. February 18, 2011 Localio AR, Lawthers AG, Brennan TA, et al. Relation between Malpractice Claims and Adverse Events Due to Negligence. New England Journal of Medicine. 2010;325(4). doi:10.1…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37803/psn-pdf
    January 06, 2017 - Paying the piper: investing in infrastructure for patient safety.  January 6, 2017 Pronovost P, Rosenstein BJ, Paine LA, et al. Paying the piper: investing in infrastructure for patient safety. Jt Comm J Qual Patient Saf. 2008;34(6):342-8. https://psnet.ahrq.gov/issue/paying-piper-investing-infrastructure-patient-…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41993/psn-pdf
    April 21, 2015 - Simulation-based trial of surgical-crisis checklists. April 21, 2015 Arriaga AF, Bader AM, Wong JM, et al. Simulation-based trial of surgical-crisis checklists. N Engl J Med. 2013;368(3):246-53. doi:10.1056/NEJMsa1204720. https://psnet.ahrq.gov/issue/simulation-based-trial-surgical-crisis-checklists Surgical check…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844043/psn-pdf
    February 08, 2023 - In situ simulation: a strategy to restore patient safety in intensive care units after the COVID-19 pandemic? February 8, 2023 Gómez-Pérez V, Escrivá Peiró D, Sancho-Cantus D, et al. In Situ Simulation: A Strategy to Restore Patient Safety in Intensive Care Units after the COVID-19 Pandemic? Systematic Review. Heal…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42836/psn-pdf
    January 08, 2014 - Comparison of medication safety effectiveness among nine critical access hospitals. January 8, 2014 Cochran GL, Haynatzki G. Comparison of medication safety effectiveness among nine critical access hospitals. Am J Health Syst Pharm. 2013;70(24):2218-24. doi:10.2146/ajhp130067. https://psnet.ahrq.gov/issue/comparis…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867091/psn-pdf
    November 06, 2024 - Initiative to deprescribe high-risk drugs for older adults presenting to the emergency department after falls. November 6, 2024 Selman K, Roberts E, Niznik J, et al. Initiative to deprescribe high?risk drugs for older adults presenting to the emergency department after falls. J Am Geriatr Soc. 2024;72(Supp 3):s60-s…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35424/psn-pdf
    April 09, 2013 - Clinical impact and frequency of anatomic pathology errors in cancer diagnoses. April 9, 2013 Raab SS, Grzybicki DM, Janosky JE, et al. Clinical impact and frequency of anatomic pathology errors in cancer diagnoses. Cancer. 2005;104(10):2205-13. https://psnet.ahrq.gov/issue/clinical-impact-and-frequency-anatomic-p…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44646/psn-pdf
    November 11, 2015 - The hidden costs of reconciling surgical sponge counts. November 11, 2015 Steelman VM, Schaapveld AG, Perkhounkova Y, et al. The Hidden Costs of Reconciling Surgical Sponge Counts. AORN J. 2015;102(5):498-506. doi:10.1016/j.aorn.2015.09.002. https://psnet.ahrq.gov/issue/hidden-costs-reconciling-surgical-sponge-coun…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38428/psn-pdf
    February 18, 2009 - Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties. February 18, 2009 Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-08-00220. https://psnet.ahrq.gov/issue/adverse-eve…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39581/psn-pdf
    January 03, 2017 - An implementation strategy for a multicenter pediatric rapid response system in Ontario. January 3, 2017 Buist MD, Shearer W. Rapid Response Systems: A Mandatory System of Care or an Optional Extra for Bedside Clinical Staff? The Joint Commission Journal on Quality and Patient Safety. 2016;36(6). doi:10.1016/s1553…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74267/psn-pdf
    January 19, 2022 - Support opportunities for second victims lessons learned: a qualitative study of the top 20 US News and World Report Honor Roll Hospitals. January 19, 2022 Marr R, Goyal A, Quinn M, et al. Support opportunities for second victims lessons learned: a qualitative study of the top 20 US News and World Report Honor Rol…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866554/psn-pdf
    August 21, 2024 - Multi-team shared expectations tool (MT-SET): an exercise to improve teamwork across health care teams. August 21, 2024 Marsteller JA, Rosen MA, Wyskiel R, et al. Multi-team shared expectations tool (MT-SET): an exercise to improve teamwork across health care teams. Jt Comm J Qual Patient Saf. 2024;50(10):737-744. …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73364/psn-pdf
    January 01, 2022 - Impact of opioid administration in the intensive care unit and subsequent use in opioid-naïve patients. June 9, 2021 Krancevich NM, Belfer JJ, Draper HM, et al. Impact of opioid administration in the intensive care unit and subsequent use in opioid-naïve patients. Ann Pharmacother. 2022;56(1):52-59. doi:10.1177/10…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/764402/psn-pdf
    March 02, 2022 - A systematic review of methods for medical record analysis to detect adverse events in hospitalized patients. March 2, 2022 Klein DO, Rennenberg RJMW, Koopmans RP, et al. A systematic review of methods for medical record analysis to detect adverse events in hospitalized patients. J Patient Saf. 2021;17(8):e1234-e12…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37776/psn-pdf
    January 31, 2011 - Barcoded medication administration: a last line of defense. January 31, 2011 Cescon DW, Etchells E. Barcoded medication administration: a last line of defense. JAMA. 2008;299(18):2200-2. doi:10.1001/jama.299.18.2200. https://psnet.ahrq.gov/issue/barcoded-medication-administration-last-line-defense Barcoding techn…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867013/psn-pdf
    October 23, 2024 - Reducing automated dispensing cabinet overrides in the peri-anesthesia care unit: a quality improvement project. October 23, 2024 Franciscovich CD, Bieniek A, Dunn K, et al. Reducing automated dispensing cabinet overrides in the peri- anesthesia care unit: a quality improvement project. Jt Comm J Qual Patient Saf. …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60591/psn-pdf
    June 17, 2020 - National trends in the safety performance of electronic health record systems from 2009 to 2018. June 17, 2020 Classen DC, Holmgren AJ, Co Z, et al. National trends in the safety performance of electronic health record systems from 2009 to 2018. JAMA Netw Open. 2020;3(5). doi:10.1001/jamanetworkopen.2020.5547. htt…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38891/psn-pdf
    January 04, 2010 - Do calculation errors by nurses cause medication errors in clinical practice? A literature review. January 4, 2010 Wright K. Do calculation errors by nurses cause medication errors in clinical practice? A literature review. Nurse Educ Today. 2010;30(1):85-97. doi:10.1016/j.nedt.2009.06.009. https://psnet.ahrq.gov/…

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