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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-…
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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,…
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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…
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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-…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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.
…
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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…
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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…
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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…
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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. …
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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…
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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/…