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psnet.ahrq.gov/node/40478/psn-pdf
June 13, 2011 - Evaluating the medication process in the context of CPOE
use: the significance of working around the system.
June 13, 2011
Niazkhani Z, Pirnejad H, van der Sijs H, et al. Evaluating the medication process in the context of CPOE
use: the significance of working around the system. Int J Med Inform. 2011;80(7):490-506…
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psnet.ahrq.gov/node/39428/psn-pdf
April 07, 2010 - Critical incidents related to cardiac arrests reported to the
Danish Patient Safety Database.
April 7, 2010
Andersen PO, Maaløe R, Andersen HB. Critical incidents related to cardiac arrests reported to the Danish
Patient Safety Database. Resuscitation. 2010;81(3):312-316. doi:10.1016/j.resuscitation.2009.10.018.
h…
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psnet.ahrq.gov/node/46224/psn-pdf
July 12, 2017 - Systematic approaches to adverse events in obstetrics,
Part 1 & Part 2.
July 12, 2017
Pettker CM. Systematic approaches to adverse events in obstetrics, Part I: Event identification and
classification. Semin Perinatol. 2017;41(3). doi:10.1053/j.semperi.2017.03.003.
https://psnet.ahrq.gov/issue/systematic-approache…
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psnet.ahrq.gov/node/42159/psn-pdf
March 04, 2015 - Peer review comments augment diagnostic error
characterization and departmental quality assurance: 1-
year experience from a children's hospital.
March 4, 2015
Iyer RS, Swanson JO, Otto RK, et al. Peer review comments augment diagnostic error characterization and
departmental quality assurance: 1-year experience f…
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psnet.ahrq.gov/node/40985/psn-pdf
December 07, 2011 - Implementing the World Health Organization surgical
safety checklist: a model for future perioperative
initiatives.
December 7, 2011
Styer KA, Ashley SW, Schmidt I, et al. Implementing the World Health Organization surgical safety
checklist: a model for future perioperative initiatives. AORN J. 2011;94(6):590-8.
…
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psnet.ahrq.gov/node/46143/psn-pdf
June 14, 2017 - Report of the Announced Inspection of Medication Safety
at the Midland Regional Hospital Tullamore, County
Offaly.
June 14, 2017
Dublin, Ireland: Health Information and Quality Authority; May 2017.
https://psnet.ahrq.gov/issue/report-announced-inspection-medication-safety-midland-regional-hospital-
tullamore-coun…
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psnet.ahrq.gov/node/42913/psn-pdf
January 29, 2014 - What to do with healthcare incident reporting systems.
January 29, 2014
Pham JC, Girard T, Pronovost PJ. What to do with healthcare Incident Reporting Systems. J Public Health
Res. 2013;2(3). doi:10.4081/jphr.2013.e27.
https://psnet.ahrq.gov/issue/what-do-healthcare-incident-reporting-systems
Incident reporting sy…
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psnet.ahrq.gov/node/41534/psn-pdf
July 25, 2012 - Protecting patients from an unsafe system: the etiology
and recovery of intraoperative deviations in care.
July 25, 2012
Hu Y-Y, Arriaga AF, Roth EM, et al. Protecting patients from an unsafe system: the etiology and recovery
of intraoperative deviations in care. Ann Surg. 2012;256(2):203-10. doi:10.1097/SLA.0b013e…
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psnet.ahrq.gov/node/73377/psn-pdf
June 09, 2021 - An examination of factors that predict the perioperative
culture of safety.
June 9, 2021
Wright MI, Polivka B, Abusalem S. An examination of factors that predict the perioperative culture of safety.
AORN J. 2021;113(5):465-475. doi:10.1002/aorn.13373.
https://psnet.ahrq.gov/issue/examination-factors-predict-periop…
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psnet.ahrq.gov/node/837847/psn-pdf
August 17, 2022 - Defining and studying errors in surgical care: a
systematic review.
August 17, 2022
Marsh KM, Turrentine FE, Knight K, et al. Defining and studying errors in surgical care: a systematic
review. Ann Surg. 2022;275(6):1067-1073. doi:10.1097/sla.0000000000005351.
https://psnet.ahrq.gov/issue/defining-and-studying-err…
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psnet.ahrq.gov/node/837703/psn-pdf
July 20, 2022 - Family safety reporting in hospitalized children with
medical complexity.
July 20, 2022
Mercer AN, Mauskar S, Baird JD, et al. Family safety reporting in hospitalized children with medical
complexity. Pediatrics. 2022;150(2):e2021055098. doi:10.1542/peds.2021-055098.
https://psnet.ahrq.gov/issue/family-safety-repo…
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psnet.ahrq.gov/node/41835/psn-pdf
May 19, 2015 - Interventions for reducing wrong-site surgery and
invasive procedures.
May 19, 2015
Algie CM, Mahar RK, Wasiak J, et al. Interventions for reducing wrong-site surgery and invasive clinical
procedures. Cochrane Database Syst Rev. 2015;3)(3):CD009404. doi:10.1002/14651858.CD009404.pub3.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/862614/psn-pdf
February 14, 2024 - Systemic failures in nursing home care--a scoping study.
February 14, 2024
Sturmberg JP, Gainsford L, Goodwin N, et al. Systemic failures in nursing home care—A scoping study. J
Eval Clin Pract. 2024. doi:10.1111/jep.13961.
https://psnet.ahrq.gov/issue/systemic-failures-nursing-home-care-scoping-study
Nursing home…
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psnet.ahrq.gov/node/863755/psn-pdf
March 06, 2024 - Nurse leader attitudes and beliefs regarding medical
errors.
March 6, 2024
Prothero MM, Huefner K, Sorhus M. Nurse leader attitudes and beliefs regarding medical errors. J Nurs
Adm. 2024;54(1):10-15. doi:10.1097/nna.0000000000001371.
https://psnet.ahrq.gov/issue/nurse-leader-attitudes-and-beliefs-regarding-medical…
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psnet.ahrq.gov/node/47146/psn-pdf
June 27, 2018 - Provider perspectives on partnering with parents of
hospitalized children to improve safety.
June 27, 2018
Rosenberg RE, Williams E, Ramchandani N, et al. Provider Perspectives on Partnering With Parents of
Hospitalized Children to Improve Safety. Hosp Pediatr. 2018;8(6):330-337. doi:10.1542/hpeds.2017-0159.
https…
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psnet.ahrq.gov/node/47324/psn-pdf
November 07, 2018 - Engaging patients to improve quality of care: a
systematic review.
November 7, 2018
Bombard Y, Baker R, Orlando E, et al. Engaging patients to improve quality of care: a systematic review.
Implement Sci. 2018;13(1):98. doi:10.1186/s13012-018-0784-z.
https://psnet.ahrq.gov/issue/engaging-patients-improve-quality-ca…
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psnet.ahrq.gov/node/42962/psn-pdf
September 07, 2016 - Drug Shortages: Public Health Threat Continues, Despite
Efforts to Help Ensure Product Availability.
September 7, 2016
Washington, DC: United States Government Accountability Office; February 10, 2014. Publication GAO-14-
194.
https://psnet.ahrq.gov/issue/drug-shortages-public-health-threat-continues-despite-effor…
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psnet.ahrq.gov/node/36917/psn-pdf
September 01, 2011 - Analysis of deaths related to anesthesia in the period
1996-2004 from closed claims registered by the Danish
Patient Insurance Association.
September 1, 2011
Hove LD, Steinmetz J, Christoffersen JK, et al. Analysis of deaths related to anesthesia in the period 1996-
2004 from closed claims registered by the Danish…
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psnet.ahrq.gov/node/36418/psn-pdf
July 14, 2010 - Application of the IV Medication Harm Index to assess the
nature of harm averted by "smart" infusion safety
systems.
July 14, 2010
Williams CK, Maddox RR, Heape E, et al. Application of the IV Medication Harm Index to Assess the
Nature of Harm Averted by "Smart" Infusion Safety Systems. J Patient Saf. 2008;2(3).
…
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psnet.ahrq.gov/node/47809/psn-pdf
April 03, 2019 - What's in a name? Provider perception of injured John
Doe patients.
April 3, 2019
Janowak CF, Agarwal SK, Zarzaur BL. What's in a Name? Provider Perception of Injured John Doe
Patients. J Surg Res. 2019;238:218-223. doi:10.1016/j.jss.2019.01.027.
https://psnet.ahrq.gov/issue/whats-name-provider-perception-injured-…