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psnet.ahrq.gov/node/42421/psn-pdf
May 19, 2014 - Do drug interaction alerts between a chemotherapy order-
entry system and an electronic medical record affect
clinician behavior?
May 19, 2014
Weingart SN, Zhu J, Young-Hong J, et al. Do drug interaction alerts between a chemotherapy order-entry
system and an electronic medical record affect clinician behavior? J …
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psnet.ahrq.gov/node/39819/psn-pdf
April 04, 2011 - Performance characteristics of a methodology to quantify
adverse events over time in hospitalized patients.
April 4, 2011
Sharek PJ, Parry G, Goldmann DA, et al. Performance characteristics of a methodology to quantify
adverse events over time in hospitalized patients. Health Serv Res. 2011;46(2):654-78. doi:10.111…
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psnet.ahrq.gov/node/38027/psn-pdf
October 15, 2008 - Assessing the Evidence Base for Context-Sensitive
Effectiveness and Safety of Patient Safety Practices:
Developing Criteria.
October 15, 2008
US Department of Health and Human Services; HHS; Agency for Healthcare Research and Quality; AHRQ.
https://psnet.ahrq.gov/issue/assessing-evidence-base-context-sensitive-eff…
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psnet.ahrq.gov/node/854383/psn-pdf
January 01, 2024 - What can safety cases offer for patient safety? A multisite
case study.
October 11, 2023
Liberati EG, Martin GP, Lamé G, et al. What can Safety Cases offer for patient safety? A multisite case
study. BMJ Qual Saf. 2024;33(3):156-165. doi:10.1136/bmjqs-2023-016042.
https://psnet.ahrq.gov/issue/what-can-safety-cases…
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psnet.ahrq.gov/node/43849/psn-pdf
January 28, 2015 - Advancing the science of measurement of diagnostic
errors in healthcare: the Safer Dx framework.
January 28, 2015
Singh H, Sittig DF. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx
framework. BMJ Qual Saf. 2015;24(2):103-110. doi:10.1136/bmjqs-2014-003675.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/72735/psn-pdf
February 10, 2021 - Deficiencies in Inpatient Mental Health Care Coordination
and Processes Prior to a Patient's Death by Suicide, Harry
S. Truman Memorial Veterans' Hospital in Columbia,
Missouri.
February 10, 2021
Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 5, 2021. Report No.
20-01521-48. …
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psnet.ahrq.gov/node/74729/psn-pdf
February 02, 2022 - Healing our own: a randomized trial to assess benefits of
peer support.
February 2, 2022
Rivera-Chiauzzi EY, Smith HA, Moore-Murray T, et al. Healing our own: a randomized trial to assess
benefits of peer support. J Patient Saf. 2022;18(1):e308-e314. doi:10.1097/pts.0000000000000771.
https://psnet.ahrq.gov/issue/h…
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psnet.ahrq.gov/node/43143/psn-pdf
April 25, 2016 - Surgical programs in the Veterans Health Administration
maintain briefing and debriefing following medical team
training.
April 25, 2016
West P, Neily J, Warner L, et al. Surgical programs in the Veterans Health Administration maintain briefing
and debriefing following medical team training. Jt Comm J Qual Patient…
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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/42264/psn-pdf
May 25, 2022 - Safety Considerations for Container Labels and Carton
Labeling Design to Minimize Medication Errors: Guidance
for Industry.
May 25, 2022
Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for
Drug Evaluation and Research; May 18, 2022.
https://psnet.ahrq.gov/issue/safe…
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psnet.ahrq.gov/node/43932/psn-pdf
March 04, 2015 - Safety considerations to mitigate the risks of
misconnections with small-bore connectors intended for
enteral applications.
March 4, 2015
Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; February
11, 2015.
https://psnet.ahrq.gov/issue/safety-considerations-mitigate-risks…
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psnet.ahrq.gov/node/840144/psn-pdf
November 16, 2022 - Dedicated teams to optimize quality and safety of
surgery: a systematic review.
November 16, 2022
Lentz CM, De Lind Van Wijngaarden RAF, Willeboordse F, et al. Dedicated teams to optimize quality and
safety of surgery: a systematic review. Int J Qual Health Care. 2022;34(4):mzac078.
doi:10.1093/intqhc/mzac078.
ht…
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psnet.ahrq.gov/node/44458/psn-pdf
September 09, 2015 - Utilizing pharmacy students in transitions-of-care
services.
September 9, 2015
L'Hommedieu T, DeCoske M, Lababidi RE, et al. Utilizing pharmacy students in transitions-of-care
services. Am J Health Syst Pharm. 2015;72(15):1266-8. doi:10.2146/ajhp140561.
https://psnet.ahrq.gov/issue/utilizing-pharmacy-students-tran…
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psnet.ahrq.gov/node/37631/psn-pdf
May 18, 2015 - The science of improvement.
May 18, 2015
Berwick DM. The science of improvement. JAMA. 2008;299(10):1182-4. doi:10.1001/jama.299.10.1182.
https://psnet.ahrq.gov/issue/science-improvement
This commentary by Dr. Donald Berwick, president of the Institute for Healthcare Improvement, addresses
the growing tension betw…
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psnet.ahrq.gov/node/36888/psn-pdf
November 30, 2016 - Hospital Survey on Patient Safety Culture: 2007
Comparative Database Report.
November 30, 2016
Sorra J, Nieva V, Famolaro T, et al. Rockville, MD: Agency for Healthcare; 2007. AHRQ publication, no. 07-
0025.
https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2007-comparative-database-report
A key…
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psnet.ahrq.gov/node/73417/psn-pdf
June 23, 2021 - Classification of failures in the perception of
conversational agents (CAs) and their implications on
patient safety.
June 23, 2021
Aftab H, Shah SHH, Habli I. Classification of failures in the perception of conversational agents (CAs) and
their implications on patient safety. Stud Health Technol Inform. 2021;281:…
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psnet.ahrq.gov/node/45124/psn-pdf
June 22, 2016 - The impact of surgical safety checklists on theatre
departments: a critical review of the literature.
June 22, 2016
Cadman V. The impact of surgical safety checklists on theatre departments: a critical review of the
literature. J Perioper Pract. 2016;26(4):62-71.
https://psnet.ahrq.gov/issue/impact-surgical-safety…
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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/73701/psn-pdf
September 15, 2021 - Simulation-based education enhances patient safety
behaviors during central venous catheter placement.
September 15, 2021
Jagneaux T, Caffery TS, Musso MW, et al. Simulation-based education enhances patient safety behaviors
during central venous catheter placement. J Patient Saf. 2021;17(6):425-429.
doi:10.1097/pt…
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psnet.ahrq.gov/node/42862/psn-pdf
January 15, 2014 - VA Health Care: Improvements Needed in Processes
Used to Address Providers' Actions That Contribute to
Adverse Events.
January 15, 2014
Draper D. Washington, DC: United States Government Accountability Office; December 3, 2013.
Publication GAO-14-55.
https://psnet.ahrq.gov/issue/va-health-care-improvements-needed…