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psnet.ahrq.gov/node/45674/psn-pdf
September 29, 2017 - Pain Management and Prescription Opioid-related Harms:
Exploring the State of the Evidence: Proceedings of a
Workshop—in Brief.
September 29, 2017
Forstag EH; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid
Abuse; Health and Medicine Division. Washington, DC: National Academy …
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psnet.ahrq.gov/node/60317/psn-pdf
May 13, 2020 - The nurse's experience of decision-making processes in
missed nursing care: a qualitative study.
May 13, 2020
Abdelhadi N, Drach?Zahavy A, Srulovici E. The nurse’s experience of decision?making processes in
missed nursing care: a qualitative study. J Adv Nurs. 2020;76(8):2161-2170. doi:10.1111/jan.14387.
https://p…
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psnet.ahrq.gov/node/46186/psn-pdf
August 02, 2017 - Pain Management and the Opioid Epidemic: Balancing
Societal and Individual Benefits and Risks of Prescription
Opioid Use.
August 2, 2017
Bonnie RJ, Ford MA, Pillips JK, eds. Washington, DC: National Academies Press; 2017.
https://psnet.ahrq.gov/issue/pain-management-and-opioid-epidemic-balancing-societal-and-indiv…
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psnet.ahrq.gov/node/46862/psn-pdf
February 21, 2018 - Considering human factors and developing systems-
thinking behaviours to ensure patient safety.
February 21, 2018
Vosper H; Lim R; Knight C; et al; CIEHF Pharmaceutical Human Factors Special Interest Group. Clinical
Pharmacist. 2018;10(2).
https://psnet.ahrq.gov/issue/considering-human-factors-and-developing-syste…
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psnet.ahrq.gov/node/45335/psn-pdf
August 10, 2016 - The Feasibility of Determining the Effectiveness and Cost-
effectiveness of Medication Organisation Devices
Compared with Usual Care for Older People in a
Community Setting: Systematic Review, Stakeholder
Focus Groups and Feasibility RCT.
August 10, 2016
Bhattacharya D, Aldus CF, Barton G, et al. Health Tech…
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psnet.ahrq.gov/node/60637/psn-pdf
July 01, 2020 - Impact of a pharmacist-administered deprescribing
intervention on nursing home residents: a randomized
controlled trial.
July 1, 2020
Balsom C, Pittman N, King R, et al. Impact of a pharmacist-administered deprescribing intervention on
nursing home residents: a randomized controlled trial. Int J Clin Pharm. 2020;4…
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psnet.ahrq.gov/node/46833/psn-pdf
December 03, 2018 - The expanding role of antimicrobial stewardship
programs in hospitals in the United States: lessons
learned from a multisite qualitative study.
December 3, 2018
Kapadia SN, Abramson EL, Carter EJ, et al. The Expanding Role of Antimicrobial Stewardship Programs in
Hospitals in the United States: Lessons Learned fro…
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psnet.ahrq.gov/node/37569/psn-pdf
March 21, 2017 - How often are potential patient safety events present on
admission?
March 21, 2017
Houchens RL, Elixhauser A, Romano PS. How often are potential patient safety events present on
admission? Jt Comm J Qual Patient Saf. 2008;34(3):154-63.
https://psnet.ahrq.gov/issue/how-often-are-potential-patient-safety-events-pres…
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psnet.ahrq.gov/node/60792/psn-pdf
August 12, 2020 - Nurse workarounds in the electronic health record: an
integrative review.
August 12, 2020
Fraczkowski D, Matson J, Lopez KD. Nurse workarounds in the electronic health record: an integrative
review. J Am Med Inform Assoc. 2020;27(7):1149-1165. doi:10.1093/jamia/ocaa050.
https://psnet.ahrq.gov/issue/nurse-workaroun…
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psnet.ahrq.gov/node/41958/psn-pdf
April 17, 2013 - Surgical never events in the United States.
April 17, 2013
Mehtsun WT, Ibrahim AM, Diener-West M, et al. Surgical never events in the United States. Surgery.
2013;153(4):465-472. doi:10.1016/j.surg.2012.10.005.
https://psnet.ahrq.gov/issue/surgical-never-events-united-states
More than a decade ago, stories of wron…
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psnet.ahrq.gov/node/37992/psn-pdf
August 20, 2008 - Medication errors reported by US family physicians and
their office staff.
August 20, 2008
Kuo GM, Phillips RL, Graham D, et al. Medication errors reported by US family physicians and their office
staff. Quality and Safety in Health Care. 2008;17(4). doi:10.1136/qshc.2007.024869.
https://psnet.ahrq.gov/issue/medic…
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psnet.ahrq.gov/node/73291/psn-pdf
May 19, 2021 - How can never event data be used to reflect or improve
hospital safety performance?
May 19, 2021
Olivarius?McAllister J, Pandit M, Sykes A, et al. How can never event data be used to reflect or improve
hospital safety performance? Anaesthesia. 2021;76(12):1616-1624. doi:10.1111/anae.15476.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/42300/psn-pdf
May 29, 2013 - Effect of noise on auditory processing in the operating
room.
May 29, 2013
Way J, Long A, Weihing J, et al. Effect of noise on auditory processing in the operating room. J Am Coll
Surg. 2013;216(5):933-8. doi:10.1016/j.jamcollsurg.2012.12.048.
https://psnet.ahrq.gov/issue/effect-noise-auditory-processing-operating…
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psnet.ahrq.gov/node/44414/psn-pdf
July 01, 2017 - From a reactive to a proactive safety approach. Analysis
of medication errors in chemotherapy using general
failure types.
July 1, 2017
Fyhr A, Ternov S, Ek Å. From a reactive to a proactive safety approach. Analysis of medication errors in
chemotherapy using general failure types. Eur J Cancer Care (Engl). 2017;2…
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psnet.ahrq.gov/node/46818/psn-pdf
April 18, 2018 - Barriers and facilitators to hospital pharmacists'
engagement in medication safety activities: a qualitative
study using the theoretical domains framework.
April 18, 2018
Mekonnen AB, McLachlan AJ, Brien J-AE, et al. Barriers and facilitators to hospital pharmacists'
engagement in medication safety activities: a q…
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psnet.ahrq.gov/node/47327/psn-pdf
August 22, 2018 - US internal medicine program director perceptions of
alignment of graduate medical education and institutional
resources for engaging residents in quality and safety.
August 22, 2018
Chacko KM, Halvorsen AJ, Swenson SL, et al. US Internal Medicine Program Director Perceptions of
Alignment of Graduate Medical Educa…
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psnet.ahrq.gov/node/46467/psn-pdf
October 18, 2017 - The Role of Clinical Learning Environments in Preparing
New Clinicians to Engage in Patient Safety.
October 18, 2017
Disch J, Kilo CM, Passiment M, Wagner R, Weiss KB; National Collaborative for Improving the Clinical
Learning Environment. Chicago, IL: Accreditation Council for Graduate Medical Education; 2017.
ht…
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psnet.ahrq.gov/node/38852/psn-pdf
April 04, 2011 - Effect of clinical pharmacists on care in the emergency
department: a systematic review.
April 4, 2011
Cohen V, Jellinek SP, Hatch A, et al. Effect of clinical pharmacists on care in the emergency department: a
systematic review. Am J Health Syst Pharm. 2009;66(15):1353-1361. doi:10.2146/ajhp080304.
https://psnet.…
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psnet.ahrq.gov/node/60881/psn-pdf
September 02, 2020 - Advancing Patient Safety: Reviews From the Agency for
Healthcare Research and Quality's Making Healthcare
Safer III Report.
September 2, 2020
Advancing Patient Safety: Reviews From the Agency for Healthcare Research and Quality’s Making
Healthcare Safer III Report. J Patient Saf. 2020;16(3S Suppl 1):s1-s56.
doi:1…
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psnet.ahrq.gov/issue/affordable-health-care-floridians-act
January 15, 2025 - Legislation/Regulation
Affordable Health Care for Floridians Act.
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August 27, 2008
Established the patient safety center in the st…