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psnet.ahrq.gov/node/36933/psn-pdf
September 09, 2011 - Retained foreign bodies after surgery.
September 9, 2011
Lincourt AE, Harrell A, Cristiano J, et al. Retained Foreign Bodies After Surgery. Journal of Surgical
Research. 2007;138(2). doi:10.1016/j.jss.2006.08.001.
https://psnet.ahrq.gov/issue/retained-foreign-bodies-after-surgery
The authors performed a case contr…
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psnet.ahrq.gov/node/41575/psn-pdf
August 08, 2012 - Threats to patient safety in the primary care office:
concerns of physicians and nurses.
August 8, 2012
Schwappach DLB, Gehring K, Battaglia M, et al. Threats to patient safety in the primary care office:
concerns of physicians and nurses. Swiss Med Wkly. 2012;142:w13601. doi:10.4414/smw.2012.13601.
https://psnet.…
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psnet.ahrq.gov/node/39049/psn-pdf
January 16, 2010 - Approaching the evidence basis for aviation-derived
teamwork training in medicine.
January 16, 2010
Zeltser M, Nash DB. Approaching the evidence basis for aviation-derived teamwork training in medicine.
Am J Med Qual. 2010;25(1):13-23. doi:10.1177/1062860609345664.
https://psnet.ahrq.gov/issue/approaching-evidence…
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psnet.ahrq.gov/node/38755/psn-pdf
July 01, 2009 - Review of Patient Safety for Children and Young People.
July 1, 2009
London, UK: National Patient Safety Agency; 2009. ISBN: 978906624071.
https://psnet.ahrq.gov/issue/review-patient-safety-children-and-young-people
Analyzing research and more than 900,000 incident reports submitted to the National Patient Safety
…
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psnet.ahrq.gov/node/40046/psn-pdf
June 15, 2012 - Applying HFMEA to prevent chemotherapy errors.
June 15, 2012
Cheng C-H, Chou C-J, Wang P-C, et al. Applying HFMEA to prevent chemotherapy errors. J Med Syst.
2012;36(3):1543-51. doi:10.1007/s10916-010-9616-7.
https://psnet.ahrq.gov/issue/applying-hfmea-prevent-chemotherapy-errors
This study provides a practical ex…
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psnet.ahrq.gov/node/34584/psn-pdf
July 08, 2014 - Advocate Health Care: a systemwide approach to quality
and safety.
July 8, 2014
Willeumier D. Advocate health care: a systemwide approach to quality and safety. Jt Comm J Qual Patient
Saf. 2004;30(10):559-566.
https://psnet.ahrq.gov/issue/advocate-health-care-systemwide-approach-quality-and-safety
Advocate is a l…
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psnet.ahrq.gov/node/38024/psn-pdf
August 27, 2008 - Promoting patient safety using an early warning scoring
system.
August 27, 2008
Higgins Y, Maries-Tillott C, Quinton S, et al. Promoting patient safety using an early warning scoring
system. Nurs Stand. 2008;22(44):35-40.
https://psnet.ahrq.gov/issue/promoting-patient-safety-using-early-warning-scoring-system
Imp…
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psnet.ahrq.gov/node/33892/psn-pdf
May 03, 2016 - Critical Incident Technique Bibliography—2001.
May 3, 2016
Fivars G; Fitzpatrick R
https://psnet.ahrq.gov/issue/critical-incident-technique-bibliography-2001
A research tool to identify critical requirements for performance in applied areas of psychology and
behavioral science. This technique, used in anesthesia t…
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psnet.ahrq.gov/node/39750/psn-pdf
August 11, 2010 - Medication reconciliation in a community pharmacy
setting.
August 11, 2010
Johnson CM, Marcy TR, Harrison DL, et al. Medication reconciliation in a community pharmacy setting. J
Am Pharm Assoc (2003). 2010;50(4):523-6. doi:10.1331/JAPhA.2010.09121.
https://psnet.ahrq.gov/issue/medication-reconciliation-community-p…
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psnet.ahrq.gov/node/39306/psn-pdf
February 17, 2010 - Detection of patient risk by nurses: a theoretical
framework.
February 17, 2010
Despins LA, Scott-Cawiezell J, Rouder JN. Detection of patient risk by nurses: a theoretical framework. J
Adv Nurs. 2010;66(2). doi:10.1111/j.1365-2648.2009.05215.x.
https://psnet.ahrq.gov/issue/detection-patient-risk-nurses-theoretica…
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psnet.ahrq.gov/node/39678/psn-pdf
July 14, 2010 - Medication errors recovered by emergency department
pharmacists.
July 14, 2010
Rothschild JM, Churchill WW, Erickson A, et al. Medication errors recovered by emergency department
pharmacists. Ann Emerg Med. 2010;55(6):513-21. doi:10.1016/j.annemergmed.2009.10.012.
https://psnet.ahrq.gov/issue/medication-errors-rec…
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psnet.ahrq.gov/node/36454/psn-pdf
January 31, 2019 - Front Line of Defense: The Role of Nurses in Preventing
Sentinel Events. Third Edition.
January 31, 2019
Oakbrook, IL: Joint Commission Resources; 2018. ISBN: 9781635850611.
https://psnet.ahrq.gov/issue/front-line-defense-role-nurses-preventing-sentinel-events-third-edition
Nurses have an important role in ensurin…
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psnet.ahrq.gov/node/39770/psn-pdf
August 18, 2010 - Comparison of potential risk factors for medication errors
with and without patient harm.
August 18, 2010
Zaal RJ, van Doormaal JE, Lenderink AW, et al. Comparison of potential risk factors for medication errors
with and without patient harm. Pharmacoepidemiol Drug Saf. 2010;19(8). doi:10.1002/pds.1977.
https://ps…
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psnet.ahrq.gov/node/42234/psn-pdf
June 03, 2013 - Pharmacovigilance using clinical notes.
June 3, 2013
LePendu P, Iyer S, Bauer-Mehren A, et al. Pharmacovigilance using clinical notes. Clin Pharmacol Ther.
2013;93(6):547-55. doi:10.1038/clpt.2013.47.
https://psnet.ahrq.gov/issue/pharmacovigilance-using-clinical-notes
This study reports on the use of natural langu…
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psnet.ahrq.gov/node/38809/psn-pdf
November 14, 2011 - Safety First: Top of Your Board's Agenda: 100 Day
Challenge Survey Report.
November 14, 2011
The Patients Association. Harrow, Middlesex, UK: The Patients Association; June 2009.
https://psnet.ahrq.gov/issue/safety-first-top-your-boards-agenda-100-day-challenge-survey-report
This publication summarizes the results…
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psnet.ahrq.gov/node/35530/psn-pdf
March 02, 2010 - Health care provider use of private sector internal error-
reporting systems.
March 2, 2010
Roumm AR, Sciamanna CN, Nash DB. Health care provider use of private sector internal error-reporting
systems. Am J Med Qual. 2005;20(6):304-12.
https://psnet.ahrq.gov/issue/health-care-provider-use-private-sector-internal-e…
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psnet.ahrq.gov/node/35951/psn-pdf
June 14, 2011 - Errors in thyroid gland fine-needle aspiration.
June 14, 2011
Raab SS, Vrbin CM, Grzybicki DM, et al. Errors in Thyroid Gland Fine-Needle Aspiration. Am J Clin Pathol.
2007;125(6). doi:10.1309/7rqe37k6439t4pb4.
https://psnet.ahrq.gov/issue/errors-thyroid-gland-fine-needle-aspiration
This AHRQ–funded study used roo…
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psnet.ahrq.gov/node/41912/psn-pdf
December 12, 2012 - Speaking up and sharing information improves trainee
neonatal resuscitations.
December 12, 2012
Katakam LI, Trickey AW, Thomas EJ. Speaking up and sharing information improves trainee neonatal
resuscitations. J Patient Saf. 2012;8(4):202-9. doi:10.1097/PTS.0b013e3182699b4f.
https://psnet.ahrq.gov/issue/speaking-an…
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psnet.ahrq.gov/node/38754/psn-pdf
August 17, 2011 - Intentionally harmful violations and patient safety: the
example of Harold Shipman.
August 17, 2011
Baker R, Hurwitz B. Intentionally harmful violations and patient safety: the example of Harold Shipman. J R
Soc Med. 2009;102(6):223-227. doi:10.1258/jrsm.2009.09k028.
https://psnet.ahrq.gov/issue/intentionally-harm…
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psnet.ahrq.gov/node/47472/psn-pdf
October 24, 2018 - Patient Safety Certificate Course.
October 24, 2018
American Board of Quality Assurance and Utilization Review Physicians; ABQAURP.
https://psnet.ahrq.gov/issue/patient-safety-certificate-course
This online course offers three modules designed to build awareness of key patient safety topics, including
how to ident…