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psnet.ahrq.gov/node/37975/psn-pdf
February 15, 2011 - A steep increase in domestic fatal medication errors with
use of alcohol and/or street drugs.
February 15, 2011
Phillips DP, Barker GEC, Eguchi MM. A steep increase in domestic fatal medication errors with use of
alcohol and/or street drugs. Arch Intern Med. 2008;168(14):1561-6. doi:10.1001/archinte.168.14.1561.
h…
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psnet.ahrq.gov/node/46782/psn-pdf
January 24, 2019 - Patient perspectives on how physicians communicate
diagnostic uncertainty: an experimental vignette study.
January 24, 2019
Bhise V, Meyer AND, Menon S, et al. Patient perspectives on how physicians communicate diagnostic
uncertainty: An experimental vignette study. Int J Qual Health Care. 2018;30(1):2-8.
doi:10.1…
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psnet.ahrq.gov/node/46450/psn-pdf
August 20, 2018 - Improving Diagnostic Quality and Safety Final Report.
August 20, 2018
Washington, DC: National Quality Forum. September 19, 2017.
https://psnet.ahrq.gov/issue/improving-diagnostic-quality-and-safety-final-report
Although diagnostic error is a well-recognized source of preventable patient harm, measuring and
mitiga…
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psnet.ahrq.gov/node/866587/psn-pdf
January 01, 2025 - Professionalising patient safety? Findings from a mixed-
methods formative evaluation of the patient safety
specialist role in the English National Health Service.
August 28, 2024
Martin G, Pralat R, Waring J, et al. Professionalising patient safety? Findings from a mixed-methods
formative evaluation of the patien…
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psnet.ahrq.gov/node/40250/psn-pdf
July 09, 2012 - Patient involvement in patient safety: how willing are
patients to participate?
July 9, 2012
Davis R, Sevdalis N, Vincent C. Patient involvement in patient safety: How willing are patients to
participate? BMJ Qual Saf. 2011;20(1):108-114. doi:10.1136/bmjqs.2010.041871.
https://psnet.ahrq.gov/issue/patient-involvem…
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psnet.ahrq.gov/node/39802/psn-pdf
November 16, 2010 - "Water cooler" learning: knowledge sharing at the clinical
"backstage" and its contribution to patient safety.
November 16, 2010
Waring J, Bishop S. "Water cooler" learning: knowledge sharing at the clinical "backstage" and its
contribution to patient safety. J Health Organ Manag. 2010;24(4):325-42.
https://psnet.…
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psnet.ahrq.gov/node/42038/psn-pdf
June 03, 2013 - A systematic review of simulation for multidisciplinary
team training in operating rooms.
June 3, 2013
Cumin D, Boyd MJ, Webster CS, et al. A systematic review of simulation for multidisciplinary team training
in operating rooms. Simul Healthc. 2013;8(3):171-179. doi:10.1097/SIH.0b013e31827e2f4c.
https://psnet.ahr…
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psnet.ahrq.gov/node/37572/psn-pdf
June 16, 2011 - Organizational factors associated with high performance
in quality and safety in academic medical centers.
June 16, 2011
Keroack MA, Youngberg BJ, Cerese JL, et al. Organizational factors associated with high performance in
quality and safety in academic medical centers. Acad Med. 2007;82(12):1178-86.
https://psne…
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psnet.ahrq.gov/node/50886/psn-pdf
February 12, 2020 - Identifying risks areas related to medication
administrations - text mining analysis using free-text
descriptions of incident reports.
February 12, 2020
Härkänen M, Paananen J, Murrells T, et al. Identifying risks areas related to medication administrations -
text mining analysis using free-text descriptions of in…
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psnet.ahrq.gov/node/38205/psn-pdf
November 12, 2008 - Characteristics of medication errors and adverse drug
events in hospitals participating in the California Pediatric
Patient Safety Initiative.
November 12, 2008
Takata GS, Taketomo CK, Waite S, et al. Characteristics of medication errors and adverse drug events in
hospitals participating in the California Pediatri…
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psnet.ahrq.gov/node/74139/psn-pdf
December 01, 2021 - Situation awareness and the mitigation of risk associated
with patient deterioration: a meta-narrative review of
theories and models and their relevance to nursing
practice.
December 1, 2021
Walshe N, Ryng S, Drennan J, et al. Situation awareness and the mitigation of risk associated with patient
deterioration: a…
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psnet.ahrq.gov/node/36208/psn-pdf
January 05, 2017 - Implementing computerized provider order entry with an
existing clinical information system.
January 5, 2017
Barron WM, Reed L, Forsythe S, et al. Implementing computerized provider order entry with an existing
clinical information system. Jt Comm J Qual Patient Saf. 2006;32(9):506-16.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/42789/psn-pdf
December 04, 2013 - Development of the just culture assessment tool:
measuring the perceptions of health-care professionals in
hospitals.
December 4, 2013
Petschonek S, Burlison JD, Cross C, et al. Development of the just culture assessment tool: measuring the
perceptions of health-care professionals in hospitals. J Patient Saf. 2013…
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psnet.ahrq.gov/node/857453/psn-pdf
December 06, 2023 - Post-implementation optimization of medication alerts in
hospital computerized provider order entry systems: a
scoping review.
December 6, 2023
Ledger TS, Brooke-Cowden K, Coiera E. Post-implementation optimization of medication alerts in hospital
computerized provider order entry systems: a scoping review. J Am M…
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psnet.ahrq.gov/node/45037/psn-pdf
February 15, 2017 - Disclosing large scale adverse events in the US Veterans
Health Administration: lessons from media responses.
February 15, 2017
Maguire EM, Bokhour BG, Asch SM, et al. Disclosing large scale adverse events in the US Veterans
Health Administration: lessons from media responses. Public Health. 2016;135:75-82.
doi:10…
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psnet.ahrq.gov/node/46197/psn-pdf
September 24, 2017 - Implementation and evaluation of a prototype consumer
reporting system for patient safety events.
September 24, 2017
Weingart SN, Weissman JS, Zimmer KP, et al. Implementation and evaluation of a prototype consumer
reporting system for patient safety events. Int J Qual Health Care. 2017;29(4):521-526.
doi:10.1093/…
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psnet.ahrq.gov/node/840170/psn-pdf
November 16, 2022 - Predicting dispensing errors in community pharmacies:
an application of the Systematic Human Error Reduction
and Prediction Approach (SHERPA).
November 16, 2022
Ashour A, Phipps DL, Ashcroft DM. PLoS ONE. 2022;17(1):e0261672.
https://psnet.ahrq.gov/innovation/predicting-dispensing-errors-community-pharmacies-…
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psnet.ahrq.gov/node/46892/psn-pdf
June 13, 2018 - AHRQ National Scorecard on Hospital-Acquired
Conditions Updated Baseline Rates and Preliminary
Results 2014–2016.
June 13, 2018
Rockville, MD: Agency for Healthcare Research and Quality; June 2018.
https://psnet.ahrq.gov/issue/ahrq-national-scorecard-hospital-acquired-conditions-updated-baseline-rates-
and-prelim…
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psnet.ahrq.gov/node/45554/psn-pdf
October 19, 2016 - Injuries before and after diagnosis of cancer: nationwide
register based study.
October 19, 2016
Shen Q, Lu D, Schelin MEC, et al. Injuries before and after diagnosis of cancer: nationwide register based
study. BMJ. 2016;354:i4218. doi:10.1136/bmj.i4218.
https://psnet.ahrq.gov/issue/injuries-and-after-diagnosis-ca…
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psnet.ahrq.gov/node/73483/psn-pdf
July 14, 2021 - Critical care nurses’ physical and mental health, worksite
wellness support, and medical errors.
July 14, 2021
Melnyk BM, Tan A, Hsieh AP, et al. Critical Care Nurses’ Physical and Mental Health, Worksite Wellness
Support, and Medical Errors. Am J Crit Care. 2021;30(3):176-184. doi:10.4037/ajcc2021301.
https://psn…