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1981. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35175/psn-pdf
      June 23, 2009 - Overnight and postcall errors in medication orders. June 23, 2009 Hendey GW, Barth BE, Soliz T. Overnight and postcall errors in medication orders. Acad Emerg Med. 2005;12(7):629-34. https://psnet.ahrq.gov/issue/overnight-and-postcall-errors-medication-orders This study examined the incidence of prescribing errors…

1982. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38061/psn-pdf
      November 08, 2008 - Medication errors in pediatric inpatients: prevalence and results of a prevention program. November 8, 2008 Otero P, Leyton A, Mariani G, et al. Medication errors in pediatric inpatients: prevalence and results of a prevention program. Pediatrics. 2008;122(3):e737-43. doi:10.1542/peds.2008-0014. https://psnet.ahrq…

1983. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38889/psn-pdf
      April 01, 2010 - Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation. April 1, 2010 Peute LW, Aarts J, Bakker PJM, et al. Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation. Int J Med Inform. 2010;79(4):e58-70. doi:…

1984. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36251/psn-pdf
      September 13, 2006 - Frequency and type of errors and near errors reported by critical care nurses. September 13, 2006 Balas MC; Scott LD; Rogers AE. https://psnet.ahrq.gov/issue/frequency-and-type-errors-and-near-errors-reported-critical-care-nurses Prior research has demonstrated that intensive care unit patients are particularly vu…

1985. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43566/psn-pdf
      December 19, 2014 - Bedside shift reports: what does the evidence say? December 19, 2014 Gregory S, Tan D, Tilrico M, et al. Bedside shift reports: what does the evidence say? J Nurs Adm. 2014;44(10):541-5. doi:10.1097/NNA.0000000000000115. https://psnet.ahrq.gov/issue/bedside-shift-reports-what-does-evidence-say Bedside shift report…

1986. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843323/psn-pdf
      February 01, 2023 - Long-Term Trends of Psychotropic Drug Use in Nursing Homes. February 1, 2023 Grimm CA. Washington DC: Office of the Inspector General; Nov 2022. Report no. OEI-07-20- 00500. https://psnet.ahrq.gov/issue/long-term-trends-psychotropic-drug-use-nursing-homes Misdiagnosis can result in inappropriate medication u…

1987. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60192/psn-pdf
      April 01, 2020 - Effective Reporting Could Improve Safe Use of Electronic Health Records. April 1, 2020 Philadelphia, PA: Pew Charitable Trusts; March 2020. https://psnet.ahrq.gov/issue/effective-reporting-could-improve-safe-use-electronic-health-records Electronic health records both enhance and challenge the safety of care proce…

1988. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35485/psn-pdf
      May 27, 2011 - Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety. May 27, 2011 Koshy R. Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety. Transfusion (Paris). 2005;45(4 Suppl):189S-205S. https://psnet.ahrq.go…

1989. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43211/psn-pdf
      July 16, 2015 - Seeking high reliability in primary care: leadership, tools, and organization. July 16, 2015 Weaver RR. Seeking high reliability in primary care: Leadership, tools, and organization. Health Care Manage Rev. 2015;40(3):183-92. doi:10.1097/HMR.0000000000000022. https://psnet.ahrq.gov/issue/seeking-high-reliability-p…

1990. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/855104/psn-pdf
      November 08, 2023 - Healthcare wants to fly as high as the aviation industry. Can it? November 8, 2023 Twenter P. Becker's Clinical Leadership. October 30, 2023. https://psnet.ahrq.gov/issue/healthcare-wants-fly-high-aviation-industry-can-it Health care has long held commercial aviation as a beacon to guide patient safety improv…

1991. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50594/psn-pdf
      October 30, 2019 - Pharmacist linkage in care transitions: from academic medical center to community. October 30, 2019 Bloodworth LS, Malinowski SS, Lirette ST, et al. Pharmacist linkage in care transitions: from academic medical center to community. J Am Pharm Assoc . 2019;59(6):896-904. doi:10.1016/j.japh.2019.08.011. https://psne…

1992. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/847731/psn-pdf
      April 19, 2023 - Lessons from health care leaders: rethinking and reinvesting in patient safety. April 19, 2023 doi:10.1056/CAT.23.0090. https://psnet.ahrq.gov/issue/lessons-health-care-leaders-rethinking-and-reinvesting-patient-safety Progress in patient safety has been disappointingly slow. This commentary shares thoughts from a…

1993. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/859351/psn-pdf
      January 01, 2024 - Changing the patient safety mindset: can safety cases help? December 20, 2023 Sujan M, Habli I. Changing the patient safety mindset: can safety cases help? BMJ Qual Saf. 2024;33(3):145-148. doi:10.1136/bmjqs-2023-016652. https://psnet.ahrq.gov/issue/changing-patient-safety-mindset-can-safety-cases-help Examinatio…

1994. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50875/psn-pdf
      February 05, 2020 - Implementing Closing the Loop. Safe Practices for Diagnostic Results February 5, 2020 Partnership for HIT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2020. https://psnet.ahrq.gov/issue/implementing-closing-loop-safe-practices-diagnostic-results Health information technology (HIT) can improve record keepi…

1995. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43462/psn-pdf
      September 12, 2016 - Preventable mortality after common urological surgery: failing to rescue? September 12, 2016 Sammon JD, Pucheril D, Abdollah F, et al. Preventable mortality after common urological surgery: failing to rescue? BJU Int. 2015;115(4):666-674. doi:10.1111/bju.12833. https://psnet.ahrq.gov/issue/preventable-mortality-af…

1996. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35101/psn-pdf
      November 04, 2015 - Hospital finances and patient safety outcomes. November 4, 2015 Encinosa W, Bernard DM. Hospital finances and patient safety outcomes. Inquiry. 2005;42(1):60-72. https://psnet.ahrq.gov/issue/hospital-finances-and-patient-safety-outcomes This AHRQ–funded study examined the relationship between hospital profit margin…

1997. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35583/psn-pdf
      June 17, 2010 - Using a bar-coded medication administration system to prevent medication errors in a community hospital network. June 17, 2010 Sakowski J, Leonard T, Colburn S, et al. Using a bar-coded medication administration system to prevent medication errors in a community hospital network. American Journal of Health-System …

1998. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837908/psn-pdf
      August 24, 2022 - Implication of the COVID-19 Pandemic for Patient Safety: A Rapid Review. August 24, 2022 Integrated Health Services. Geneva, Switzerland: World Health Organization; 2022. ISBN: 9789240055094. https://psnet.ahrq.gov/issue/implication-covid-19-pandemic-patient-safety-rapid-review The COVID-19 pandemic created new r…

1999. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44017/psn-pdf
      April 08, 2018 - Digitizing diagnosis: a review of mobile applications in the diagnostic process. April 8, 2018 Jutel A, Lupton D. Digitizing diagnosis: a review of mobile applications in the diagnostic process. Diagnosis (Berl). 2015;2(2):89-96. doi:10.1515/dx-2014-0068. https://psnet.ahrq.gov/issue/digitizing-diagnosis-review-mo…

2000. Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital. | PSNet
      psnet.ahrq.gov/issue/deny-dismiss-dehumanise-what-happened-when-i-went-hospital
      September 09, 2015 - March 18, 2020 Examining causes and prevention strategies of adverse events in deceased