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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.
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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…
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psnet.ahrq.gov/node/44791/psn-pdf
January 13, 2016 - FDA Drug Safety Communication: FDA cautions about
dosing errors when switching between different oral
formulations of antifungal Noxafil (posaconazole); label
changes approved.
January 13, 2016
US Food and Drug Administration; FDA.
https://psnet.ahrq.gov/issue/fda-drug-safety-communication-fda-cautions-about-dosi…
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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/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…
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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
…
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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…
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psnet.ahrq.gov/node/46216/psn-pdf
July 12, 2017 - Physician satisfaction with transition from CPOE to
paper-based prescription.
July 12, 2017
Griffon N, Schuers M, Joulakian M, et al. Physician satisfaction with transition from CPOE to paper-based
prescription. Int J Med Inform. 2017;103:42-48. doi:10.1016/j.ijmedinf.2017.04.007.
https://psnet.ahrq.gov/issue/phys…
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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…
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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/852448/psn-pdf
January 01, 2024 - A realist synthesis of interprofessional patient safety
activities and healthcare student attitudes towards patient
safety.
August 16, 2023
Cleary E, Bloomfield J, Frotjold A, et al. A realist synthesis of interprofessional patient safety activities and
healthcare student attitudes towards patient safety. J Interp…
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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…
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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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www.ahrq.gov/patient-safety/settings/hospital/match/table-5.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Table 5: Identifying Challenges and Addressing Barriers
Previous Page Next Page
Table of Contents
Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Introducti…
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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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www.ahrq.gov/research/shuttered/toolkitchecklist/facadvcare.html
July 01, 2018 - Facilities/Advanced Patient Care
Layout and potential use of former advanced care areas for general surge. Aspects being evaluated for general surge capacity, not for original purposes.
Date: ____________ Location: _______________________ Team member: __________________________
Operating Rooms
Observati…