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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72584/psn-pdf
    December 16, 2020 - Hidden medication loss when using a primary administration set for small-volume intermittent infusions. December 16, 2020 ISMP Medication Safety Alert! Acute care edition. December 3, 2020;25(24). https://psnet.ahrq.gov/issue/hidden-medication-loss-when-using-primary-administration-set-small-volume- intermittent …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44872/psn-pdf
    February 12, 2016 - Reducing preventable harm in hospitals. February 12, 2016 Bornstein D. New York Times. January 26, and February 2, 2016. https://psnet.ahrq.gov/issue/reducing-preventable-harm-hospitals Discussing the importance of designing safeguards to prevent system failures that can result in patient harm, this two-part newsp…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35417/psn-pdf
    February 15, 2010 - Errors in laboratory medicine: practical lessons to improve patient safety. February 15, 2010 Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab Med. 2005;129(10):1252-1261. https://psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patie…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45520/psn-pdf
    October 05, 2016 - Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic error. October 5, 2016 Foster PN, Klein JR. Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic error. J Community Hosp Intern Med Perspect. 2016;6(4):31994. doi:10.3402/jchimp.v6.31994. http…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46808/psn-pdf
    February 14, 2018 - Anesthesia medication handling needs a new vision. February 14, 2018 Grigg EB, Roesler A. Anesthesia Medication Handling Needs a New Vision. Anesth Analg. 2018;126(1):346-350. doi:10.1213/ANE.0000000000002521. https://psnet.ahrq.gov/issue/anesthesia-medication-handling-needs-new-vision Anesthesiology has been a le…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47967/psn-pdf
    May 01, 2019 - The Harvard Medical Practice Study trigger system performance in deceased patients. May 1, 2019 Klein DO, Rennenberg RJMW, Koopmans RP, et al. The Harvard medical practice study trigger system performance in deceased patients. BMC Health Serv Res. 2019;19(1):16. doi:10.1186/s12913-018-3839-6. https://psnet.ahrq.go…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72778/psn-pdf
    February 24, 2021 - Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety. February 24, 2021 Mahadevan K, Cowan E, Kalsi N, et al. Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety. Open Heart. 2020;7(2). doi:10.1136/openhrt-2020-001260. h…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60876/psn-pdf
    September 02, 2020 - Serious adverse events in pediatric procedural sedation before and after the implementation of a pre-sedation checklist. September 2, 2020 Librov S, Shavit I. Serious adverse events in pediatric procedural sedation before and after the implementation of a pre-sedation checklist. J Pain Res. 2020;13:1797-1802. doi:…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866647/psn-pdf
    September 04, 2024 - Diagnostic discrepancies in the emergency department: a retrospective study. September 4, 2024 Schols LA, Maranus ME, Rood PPM, et al. Diagnostic discrepancies in the emergency department: a retrospective study. J Patient Saf. 2024;20(6):420-425. doi:10.1097/pts.0000000000001252. https://psnet.ahrq.gov/issue/diagn…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50408/psn-pdf
    October 02, 2019 - Delayed Admissions to the Pediatric Intensive Care Unit: Progression of Disease or Errors in Emergency Department Management October 2, 2019 Czolgosz T, Cashen K, Farooqi A, et al. Delayed Admissions to the Pediatric Intensive Care Unit: Progression of Disease or Errors in Emergency Department Management. Pediatr …

  11. Final Progress Report: Medication Reconciliation: Bridging Communications Across the Continuum of Care (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/muller-report.pdf
    January 01, 2024 - Final Progress Report: Medication Reconciliation: Bridging Communications Across the Continuum of Care Title: Medication Reconciliation: Bridging Communications Across the Continuum of Care Principal Investigator and Team Members: Melinda Muller, MD, Lynn Belcher, RPh, Melissa Blanchard, MP, Amy Caster-Winegeart, …

  12. Screening for Anxiety in Children and Adolescents: US Preventive Services Recommendation Statement (pdf file)

    www.uspreventiveservicestaskforce.org/home/getfilebytoken/qWZxPBqpffTYVNvGYPkohz
    May 01, 2021 - Screening for Anxiety in Children and Adolescents: US Preventive Services Recommendation Statement Screening for Anxiety in Children and Adolescents US Preventive Services Task Force Recommendation Statement US Preventive Services Task Force Summary of Recommendations See the Summary of Recommendations figure. Imp…

  13. In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
    February 26, 2025 - In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Essay View more articles from the same authors. Citation Text: Savitz LA, S…

  14. Research Protocol for Interventions for Substance Use Disorders in Adolescents: A Systematic Review (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/suda-final-protocol.pdf
    October 02, 2018 - Research Protocol for Interventions for Substance Use Disorders in Adolescents: A Systematic Review Evidence-based Practice Center Systematic Review Protocol Project Title: Interventions for Substance Use Disorders in Adolescents: A Systematic Review I. Background and Objectives for the Systematic Revie…

  15. Learning Health Systems for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
    February 26, 2025 - Learning Health Systems for Patient Safety Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Conversation View more articles from the same authors. Citation Text: Savitz LA, Sousane Z, Mossburg SE. Learning …

  16. R18Hs017216-Johnson-Final-Report-2011 (pdf file)

    digital.ahrq.gov/sites/default/files/docs/publication/r18hs017216-johnson-final-report-2011.pdf
    January 01, 2011 - Progress Report 5 R18 HS017216-03 Johnson, Kevin B., MD, MS 1 STEPStools: Developing Web Services for Safe Pediatric Dosing Kevin B. Johnson, MD, MS (PI) Professor, Biomedical Informatics Professor, Pediatrics Vanderbilt University Medical Center Nashville, TN Cynthia S. Gadd, PhD (Co-Investigato…

  17. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update - Evidence Summary (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/noninvasive-nonpharm-pain-summary.pdf
    April 01, 2020 - We focused on evaluating the persistence of effects for therapies at least 1 month beyond the course … We focused on evaluating the sustainability of effects for at least 1 month postintervention.

  18. Chapter 2 | Agency for Healthcare Research and Quality

    www.ahrq.gov/prevention/resources/vision/resources/vision2.html
    October 01, 2002 - Chapter 2 Vision Rehabilitation: Care and Benefit Plan Models: Literature Review Applying the Framework to Vision Rehabilitation The American Occupational Therapy Association (AOTA) 28 describes two national systems that exist to serve people with visual impairments—the blindness system and the health ca…

  19. Slide 1

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/engaging-nurse-physician-patient.pptx
    May 28, 2015 - Slide 1 Engaging The Nurse, Physician, Patient/Family; CUSP – Learn from Defects Jenny Tuttle, RN, MSNEd, CNRN Clinical Nurse Leader Neuro/Medical/Surgical ICU Tucson Medical Center Tucson, Arizona Christin Ko, MD, MBA, SFHM, FACP Assistant Professor Feinberg School of Medicine Northwestern University Chicago, IL …

  20. Engage the Senior Executive Facilitator Notes | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cusp/modules/engage/exec-notes.html
    December 01, 2012 - Engage the Senior Executive Facilitator Notes CUSP Toolkit The Engage the Senior Executive module of the CUSP Toolkit focuses on the role and responsibilities of the senior executive within the CUSP team. Engaging a senior executive to partner with a unit will bridge the gap between senior management and fron…
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