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psnet.ahrq.gov/issue/effect-electronic-medication-reconciliation-application-and-process-redesign-potentialJune 09, 2011 - Study Classic Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial. Citation Text: Schnipper JL, Hamann C, Ndumele CD, et al. Effect of an electronic medication reconcil…
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psnet.ahrq.gov/issue/potentially-severe-incidents-during-interhospital-transport-critically-ill-patientsOctober 26, 2022 - Study Potentially severe incidents during interhospital transport of critically ill patients, frequently occurring but rarely reported: a prospective study. Citation Text: Eiding H, Røise O, Kongsgaard UE. Potentially severe incidents during interhospital transport of critically ill pati…
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psnet.ahrq.gov/issue/patient-reported-incident-hospital-instrument-prih-i-assessments-data-quality-test-retestMarch 20, 2015 - Study The Patient-Reported Incident in Hospital Instrument (PRIH-I): assessments of data quality, test–retest reliability and hospital-level reliability. Citation Text: Bjertnaes O, Skudal KE, Iversen HH, et al. The Patient-Reported Incident in Hospital Instrument (PRIH-I): assessment…
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psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgerySeptember 15, 2024 - December 18, 2024 Grading recommendations for enhanced patient safety in sentinel event
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39818/psn-pdfJanuary 04, 2011 - Diagnostic error in a national incident reporting system in the UK. January 4, 2011 Sevdalis N, Jacklin R, Arora S, et al. Diagnostic error in a national incident reporting system in the UK. J Eval Clin Pract. 2010;16(6):1276-81. doi:10.1111/j.1365-2753.2009.01328.x. https://psnet.ahrq.gov/issue/diagnostic-error-n… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41623/psn-pdfApril 05, 2013 - Preventing patient harms through systems of care. April 5, 2013 Pronovost P, Bo-Linn GW. Preventing patient harms through systems of care. JAMA. 2012;308(8):769-70. doi:10.1001/jama.2012.9537. https://psnet.ahrq.gov/issue/preventing-patient-harms-through-systems-care Recent initiatives, such as the Partnership for… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/74095/psn-pdfFebruary 01, 2022 - Zero Suicide Initiative. November 17, 2021 Office of the Federal Register, National Archives and Records Administration. Fed Register. November 3, 2021;(86):60883-60893. https://psnet.ahrq.gov/issue/zero-suicide-initiative Patient suicide attempts are considered never events. This funding announcement calls for pr… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45241/psn-pdfOctober 31, 2023 - Hospital Harm Project. October 31, 2023 Canadian Institute for Health Information, Health Excellence Canada. https://psnet.ahrq.gov/issue/hospital-harm-project Reducing preventable harm associated with health care is a worldwide goal. This Canadian initiative developed a measure to track unintended harm in acute c… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72831/psn-pdfMarch 10, 2021 - Enhancing a culture of safety through disclosure of adverse events. March 10, 2021 Cornelissen C, Call RC, Harbell MW, et al. APSF Newsletter. February 202136(1);25-27 https://psnet.ahrq.gov/issue/enhancing-culture-safety-through-disclosure-adverse-events Error disclosure is supported by a robust safety … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836788/psn-pdfMarch 23, 2022 - A widow’s mission to change NC dental sedation rules. March 23, 2022 Blythe A. NC Health News. March 10, 2022 https://psnet.ahrq.gov/issue/widows-mission-change-nc-dental-sedation-rules Patient harm in dentistry is receiving increased attention and scrutiny. This story covers a medication incident and the lack of … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/74709/psn-pdfNovember 23, 2024 - Fire safety in the operating room. November 23, 2024 Ehrenwerth J. UptoDate. November 18, 2024. https://psnet.ahrq.gov/issue/fire-safety-operating-room Operating room fires are never events that, while rare, still harbor great potential for harm. This review discusses settings prone to surgical fire events, preven… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46408/psn-pdfNovember 29, 2017 - Eliminating vincristine administration events. November 29, 2017 Quick Safety. October 16, 2017;(37):1-3. https://psnet.ahrq.gov/issue/eliminating-vincristine-administration-events Vincristine administration errors can have serious consequences. This newsletter article outlines steps to reduce risks associated wit… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45558/psn-pdfMay 10, 2017 - Prevention Is Better Than Cure: Learning From Adverse Events in Healthcare. May 10, 2017 Leistikow I. Boca Raton, FL: CRC Press; 2017. ISBN: 9781138197763. https://psnet.ahrq.gov/issue/prevention-better-cure-learning-adverse-events-healthcare Patients continue to experience preventable health care–associated harm.… -
psnet.ahrq.gov/periodic-issue/periodic-issue-354August 05, 2022 - found that abortion-related morbidity or adverse events occurred in nearly 4% of abortions but that event … 2022. 12:00pm-5:00pm (EST) Root cause analysis (RCA) is an established adverse event
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46822/psn-pdfApril 12, 2019 - Effect of an in-hospital multifaceted clinical pharmacist intervention on the risk of readmission: a randomized clinical trial. April 12, 2019 Ravn-Nielsen LV, Duckert M-L, Lund ML, et al. Effect of an In-Hospital Multifaceted Clinical Pharmacist Intervention on the Risk of Readmission: A Randomized Clinical Trial… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36932/psn-pdfSeptember 01, 2011 - Cost-effectiveness of an electronic medication ordering and administration system in reducing adverse drug events. September 1, 2011 Wu RC, Laporte A, Ungar WJ. Cost-effectiveness of an electronic medication ordering and administration system in reducing adverse drug events. J Eval Clin Pract. 2007;13(3):440-8. h… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837980/psn-pdfMarch 21, 2024 - Diagnostic errors. March 21, 2024 Raffel K, Ranji S. UpToDate. February 8, 2024. https://psnet.ahrq.gov/issue/diagnostic-errors Diagnostic mistakes are common contributors to preventable patient harm. This review highlights primary areas of diagnostic error concerns (vascular events, infections, and cancers) … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41287/psn-pdfMay 17, 2012 - Economic evaluation in patient safety: a literature review of methods. May 17, 2012 de Rezende BA, Or Z, Com-Ruelle L, et al. Economic evaluation in patient safety: a literature review of methods. BMJ Qual Saf. 2012;21(6):457-65. doi:10.1136/bmjqs-2011-000191. https://psnet.ahrq.gov/issue/economic-evaluation-patie… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43415/psn-pdfSeptember 10, 2014 - Project BOOST implementation: lessons learned. September 10, 2014 Williams M, Li J, Hansen LO, et al. Project BOOST implementation: lessons learned. South Med J. 2014;107(7):455-65. doi:10.14423/SMJ.0000000000000140. https://psnet.ahrq.gov/issue/project-boost-implementation-lessons-learned This qualitative study o… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40558/psn-pdfMay 20, 2019 - Patient Safety in the Context of Perinatal, Neonatal, and Pediatric Care. May 20, 2019 Eunice Kennedy Shriver National Institute of Child Health and Human Development; NICHD; National Institutes of Health; NIH. https://psnet.ahrq.gov/issue/patient-safety-context-perinatal-neonatal-and-pediatric-care This dual-com…
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