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psnet.ahrq.gov/node/38637/psn-pdf
September 24, 2016 - Work interruptions and their contribution to medication
administration errors: an evidence review. … Work interruptions and their contribution to medication
administration errors: an evidence review. … //psnet.ahrq.gov/issue/work-interruptions-and-their-contribution-medication-administration-errors-
evidence-review … https://psnet.ahrq.gov/issue/work-interruptions-and-their-contribution-medication-administration-errors-evidence-review … https://psnet.ahrq.gov/issue/work-interruptions-and-their-contribution-medication-administration-errors-evidence-review
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psnet.ahrq.gov/node/40798/psn-pdf
September 21, 2011 - Evidence under judgment: can we oversee our own
decision making? … Evidence Under Judgment. Arch Intern Med. 2011;171(16).
doi:10.1001/archinternmed.2011.355. … https://psnet.ahrq.gov/issue/evidence-under-judgment-can-we-oversee-our-own-decision-making
This commentary … suggests that combining evidence-driven rules and clinician judgment is necessary to
improve patient … https://psnet.ahrq.gov/issue/evidence-under-judgment-can-we-oversee-our-own-decision-making
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psnet.ahrq.gov/node/34766/psn-pdf
March 05, 2013 - https://psnet.ahrq.gov/issue/making-health-care-safer-critical-analysis-patient-safety-practices
Most evidence … This one, which reviewed the state of the
evidence behind nearly 80 different safety practices (including … effort to subject safety practices
to the same scrutiny as other clinical practices in terms of their evidence … Readers are cautioned that evidence
reports have limited shelf-lives, and it is worth reviewing recent … https://psnet.ahrq.gov/issue/safe-sound-patient-safety-meets-evidence-based-medicine
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psnet.ahrq.gov/node/44746/psn-pdf
January 20, 2016 - Creating a culture of safety around bar-code medication
administration: an evidence-based evaluation … Creating a Culture of Safety Around Bar-Code Medication
Administration: An Evidence-Based Evaluation … https://psnet.ahrq.gov/issue/creating-culture-safety-around-bar-code-medication-administration-evidence … commentary discusses an evaluation process that
engages hospital leaders and frontline nurses in reviewing evidence … https://psnet.ahrq.gov/issue/creating-culture-safety-around-bar-code-medication-administration-evidence-based-evaluation
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psnet.ahrq.gov/node/43783/psn-pdf
January 14, 2015 - Improving the quality and safety of care on the medical
ward: a review and synthesis of the evidence … Improving the quality and safety of care on the medical ward: A
review and synthesis of the evidence … https://psnet.ahrq.gov/issue/improving-quality-and-safety-care-medical-ward-review-and-synthesis-
evidence-base … The authors advocate for
increasing the evidence base in all of these areas, as gaps in implementation … https://psnet.ahrq.gov/issue/improving-quality-and-safety-care-medical-ward-review-and-synthesis-evidence-base
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psnet.ahrq.gov/node/40025/psn-pdf
December 21, 2014 - Evaluating an evidence-based bundle for preventing
surgical site infection. … Evaluating an evidence-based bundle for preventing surgical
site infection: a randomized trial. … of evidence-based interventions have resulted in notable successes in patient safety, particularly … However, despite implementing five
evidence-based practices in a bundled approach, the incidence of … https://psnet.ahrq.gov/issue/evaluating-evidence-based-bundle-preventing-surgical-site-infection
https
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psnet.ahrq.gov/node/47001/psn-pdf
August 17, 2018 - Realist synthesis of intentional rounding in hospital
wards: exploring the evidence of what works, for … Realist synthesis of intentional rounding in hospital wards: exploring the
evidence of what works, for … https://psnet.ahrq.gov/issue/realist-synthesis-intentional-rounding-hospital-wards-exploring-evidence-what … In this study, researchers found limited evidence to support this approach. … https://psnet.ahrq.gov/issue/realist-synthesis-intentional-rounding-hospital-wards-exploring-evidence-what-works-whom-what
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psnet.ahrq.gov/node/33917/psn-pdf
December 22, 2014 - Evidence Report/Technology Assessment. … https://psnet.ahrq.gov/issue/effect-health-care-working-conditions-patient-safety-evidence-
reporttechnology-assessment … This report summarizes existing scientific evidence on the role health care working conditions play … https://psnet.ahrq.gov/issue/effect-health-care-working-conditions-patient-safety-evidence-reporttechnology-assessment … https://psnet.ahrq.gov/issue/effect-health-care-working-conditions-patient-safety-evidence-reporttechnology-assessment
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psnet.ahrq.gov/node/39824/psn-pdf
December 06, 2010 - Team working in intensive care: current evidence and
future endeavors. … Team working in intensive care: current evidence and future
endeavors. … https://psnet.ahrq.gov/issue/team-working-intensive-care-current-evidence-and-future-endeavors
This … evidence-based discussion identifies organizational factors that contribute to effective teamwork in … https://psnet.ahrq.gov/issue/team-working-intensive-care-current-evidence-and-future-endeavors
https:
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psnet.ahrq.gov/node/36993/psn-pdf
September 15, 2011 - A transdisciplinary team acting on evidence through
analyses of moot malpractice cases. … A transdisciplinary team acting on evidence through analyses of moot malpractice cases. … https://psnet.ahrq.gov/issue/transdisciplinary-team-acting-evidence-through-analyses-moot-malpractice … https://psnet.ahrq.gov/issue/transdisciplinary-team-acting-evidence-through-analyses-moot-malpractice-cases … https://psnet.ahrq.gov/issue/transdisciplinary-team-acting-evidence-through-analyses-moot-malpractice-cases
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psnet.ahrq.gov/node/35879/psn-pdf
July 23, 2010 - Preventing vincristine administration errors: does
evidence support minibag infusions? … Preventing Vincristine Administration Errors: Does Evidence Support Minibag
Infusions? … https://psnet.ahrq.gov/issue/preventing-vincristine-administration-errors-does-evidence-support-minibag … https://psnet.ahrq.gov/issue/preventing-vincristine-administration-errors-does-evidence-support-minibag-infusions … https://psnet.ahrq.gov/issue/preventing-vincristine-administration-errors-does-evidence-support-minibag-infusions
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - Center
History of MHS
• 1999 Institute of Medicine: To Err is Human
• MHS Reports – collection of evidence … • How effective are the PSPs, what are their unintended effects,
and what new evidence has been published … • Rapid responses were used for topics with limited recent
evidence.
12
Topics
13
Option Year … Options
• STRONGLY ENCOURAGED for improving patient safety: Evidence is strong enough to be
certain … that rapid response
systems (RRS) are effective in reducing cardiorespiratory arrest,
but evidence
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psnet.ahrq.gov/node/45147/psn-pdf
May 25, 2016 - Are evidence-based practices associated with effective
prevention of hospital-acquired pressure ulcers … Are Evidence-based Practices Associated With Effective
Prevention of Hospital-acquired Pressure Ulcers … https://psnet.ahrq.gov/issue/are-evidence-based-practices-associated-effective-prevention-hospital- … This study used administrative data to demonstrate that adoption
of evidence-based strategies and implementation … https://psnet.ahrq.gov/issue/are-evidence-based-practices-associated-effective-prevention-hospital-acquired-pressure
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psnet.ahrq.gov/node/41064/psn-pdf
March 02, 2012 - Blending evidence and innovation: improving intershift
handoffs in a multihospital setting. … Blending evidence and innovation: improving intershift handoffs in a
multihospital setting. … https://psnet.ahrq.gov/issue/blending-evidence-and-innovation-improving-intershift-handoffs-multihospital … https://psnet.ahrq.gov/issue/blending-evidence-and-innovation-improving-intershift-handoffs-multihospital-setting … https://psnet.ahrq.gov/issue/blending-evidence-and-innovation-improving-intershift-handoffs-multihospital-setting
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psnet.ahrq.gov/node/35413/psn-pdf
September 11, 2009 - Lessons learned: basic evidence-based advice for
preventing medication errors in children. … Lessons learned: basic evidence-based advice for preventing medication errors in children. … https://psnet.ahrq.gov/issue/lessons-learned-basic-evidence-based-advice-preventing-medication-errors … https://psnet.ahrq.gov/issue/lessons-learned-basic-evidence-based-advice-preventing-medication-errors-children … https://psnet.ahrq.gov/issue/lessons-learned-basic-evidence-based-advice-preventing-medication-errors-children
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psnet.ahrq.gov/node/42762/psn-pdf
November 27, 2013 - Motivational antecedents of incident reporting: evidence
from a survey of nurses and physicians. … Motivational antecedents of incident reporting: evidence from a survey
of nurses and physicians. … https://psnet.ahrq.gov/issue/motivational-antecedents-incident-reporting-evidence-survey-nurses-and- … https://psnet.ahrq.gov/issue/motivational-antecedents-incident-reporting-evidence-survey-nurses-and-physicians … https://psnet.ahrq.gov/issue/motivational-antecedents-incident-reporting-evidence-survey-nurses-and-physicians
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psnet.ahrq.gov/node/43484/psn-pdf
September 17, 2014 - A review of the evidence of harm from self-tests. … A review of the evidence of harm from self-tests. … https://psnet.ahrq.gov/issue/review-evidence-harm-self-tests
This review explored the evidence on self-tests … https://psnet.ahrq.gov/issue/review-evidence-harm-self-tests
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psnet.ahrq.gov/node/36814/psn-pdf
March 28, 2011 - Medication errors in paediatric care: a systematic review
of epidemiology and an evaluation of evidence … Medication errors in paediatric care: a systematic review of
epidemiology and an evaluation of evidence … psnet.ahrq.gov/issue/medication-errors-paediatric-care-systematic-review-epidemiology-and-
evaluation-evidence … strategies for
reducing medication errors and discovered that none of them were based on pediatric evidence … psnet.ahrq.gov/issue/medication-errors-paediatric-care-systematic-review-epidemiology-and-evaluation-evidence
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psnet.ahrq.gov/node/38625/psn-pdf
November 19, 2009 - study: a cluster
randomised trial on the development and testing of an
evidence based inpatient safety … study: a cluster
randomised trial on the development and testing of an evidence based inpatient safety … /psnet.ahrq.gov/issue/design-safe-or-sorry-study-cluster-randomised-trial-development-and-testing-
evidence-based … This study describes the implementation of a patient safety program focused on evidence-based guidelines … ://psnet.ahrq.gov/issue/design-safe-or-sorry-study-cluster-randomised-trial-development-and-testing-evidence-based
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psnet.ahrq.gov/node/41588/psn-pdf
August 15, 2012 - Implementation of an evidence-based extubation
checklist to reduce extubation failure in patients with … Implementation of an evidence-based extubation checklist to reduce extubation
failure in patients with … https://psnet.ahrq.gov/issue/implementation-evidence-based-extubation-checklist-reduce-extubation-
failure-patients-trauma … https://psnet.ahrq.gov/issue/implementation-evidence-based-extubation-checklist-reduce-extubation-failure-patients-trauma … https://psnet.ahrq.gov/issue/implementation-evidence-based-extubation-checklist-reduce-extubation-failure-patients-trauma