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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35038/psn-pdf
    January 02, 2017 - Using Six Sigma to reduce medication errors in a home- delivery pharmacy service. January 2, 2017 Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24. https://psnet.ahrq.gov/issue/using-six-sigma-redu…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865702/psn-pdf
    May 01, 2024 - Judgment errors in surgical care. May 1, 2024 Marsh KM, Turrentine FE, Jin R, et al. Judgment errors in surgical care. J Am Coll Surg. 2024;238(5):874- 879. doi:10.1097/xcs.0000000000001011. https://psnet.ahrq.gov/issue/judgment-errors-surgical-care Knowing when judgment errors are more likely to occur can increas…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42673/psn-pdf
    October 30, 2013 - Clinical evaluation of the ADE scorecards as a decision support tool for adverse drug event analysis and medication safety management. October 30, 2013 Hackl WO, Ammenwerth E, Marcilly R, et al. Clinical evaluation of the ADE scorecards as a decision support tool for adverse drug event analysis and medication safe…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42994/psn-pdf
    March 26, 2014 - Conditions that influence the impact of malpractice litigation risk on physicians' behavior regarding patient safety. March 26, 2014 Renkema E, Broekhuis M, Ahaus K. Conditions that influence the impact of malpractice litigation risk on physicians' behavior regarding patient safety. BMC Health Serv Res. 2014;14:38…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837426/psn-pdf
    June 15, 2022 - The frequency and nature of prescribing problems by general practitioners in training (REVISiT). June 15, 2022 Salema N-E, Bell BG, Marsden K, et al. The frequency and nature of prescribing problems by general practitioners in training (REVISiT). BJGP Open. 2022;6(3):BJGPO.2021.0231. doi:10.3399/bjgpo.2021.0231. …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843521/psn-pdf
    February 01, 2023 - How providers can optimize effective and safe scribe use: a qualitative study. February 1, 2023 Corby S, Ash JS, Florig ST, et al. How providers can optimize effective and safe scribe use: a qualitative study. J Gen Intern Med. 2023;38(9):2052-2058. doi:10.1007/s11606-022-07942-2. https://psnet.ahrq.gov/issue/how-…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43843/psn-pdf
    February 11, 2015 - Impact of a clinical decision support system for high-alert medications on the prevention of prescription errors. February 11, 2015 Lee JH, Han H, Ock M, et al. Impact of a clinical decision support system for high-alert medications on the prevention of prescription errors. Int J Med Inform. 2014;83(12). doi:10.101…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34998/psn-pdf
    June 22, 2009 - Cause and effect analysis of closed claims in obstetrics and gynecology. June 22, 2009 White AA, Pichert JW, Bledsoe SH, et al. Cause and effect analysis of closed claims in obstetrics and gynecology. Obstet Gynecol. 2005;105(5 Pt 1):1031-1038. https://psnet.ahrq.gov/issue/cause-and-effect-analysis-closed-claims-o…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60038/psn-pdf
    March 11, 2020 - Errors associated with oxytocin use: a multi-organization analysis by ISMP and ISMP Canada. March 11, 2020 ISMP Medication Safety Alert! Acute care edition. February 13, 2020;25(3):1-6. https://psnet.ahrq.gov/issue/errors-associated-oxytocin-use-multi-organization-analysis-ismp-and-ismp- canada Errors in IV …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38333/psn-pdf
    January 14, 2009 - Adverse Events in Hospitals: Overview of Key Issues. January 14, 2009 Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470. https://psnet.ahrq.gov/issue/adverse-events-hospitals-overview-key-issues The Tax Relief and Hea…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39460/psn-pdf
    March 23, 2011 - Applying root cause analysis to improve patient safety: decreasing falls in postpartum women. March 23, 2011 Chen K-H, Chen L-R, Su S. Applying root cause analysis to improve patient safety: decreasing falls in postpartum women. Qual Saf Health Care. 2010;19(2):138-43. doi:10.1136/qshc.2008.028787. https://psnet.a…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40958/psn-pdf
    January 19, 2012 - Do older patients' perceptions of safety highlight barriers that could make their care safer during organisational care transfers? January 19, 2012 Scott J, Dawson P, Jones D. Do older patients' perceptions of safety highlight barriers that could make their care safer during organisational care transfers? BMJ Qual…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838016/psn-pdf
    January 02, 2021 - Racism as a Root Cause approach: a new framework. January 2, 2021 Malawa Z, Gaarde J, Spellen S. Racism as a Root Cause approach: a new framework. Pediatrics. 2021;147(1):e2020015602. doi:10.1542/peds.2020-015602. https://psnet.ahrq.gov/issue/racism-root-cause-approach-new-framework Structural racism, which manife…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861769/psn-pdf
    January 31, 2024 - Psychological safety and hierarchy in operating room debriefing: reflexive thematic analysis. January 31, 2024 McElroy C, Skegg E, Mudgway M, et al. Psychological safety and hierarchy in operating room debriefing: reflexive thematic analysis. J Surg Res. 2023;295:567-573. doi:10.1016/j.jss.2023.11.054. https://psn…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866963/psn-pdf
    October 16, 2024 - FDA’s promised guidance on pulse oximeters unlikely to end decades of racial bias. October 16, 2024 Allen A. FDA’s promised guidance on pulse oximeters unlikely to end decades of racial bias. KFF Health News. October 07, 2024; https://psnet.ahrq.gov/issue/fdas-promised-guidance-pulse-oximeters-unlikely-end-decades…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47697/psn-pdf
    April 03, 2019 - Engineering a foundation for partnership to improve medication safety during care transitions. April 3, 2019 Xiao Y, Abebe E, Gurses AP. Engineering a Foundation for Partnership to Improve Medication Safety during Care Transitions. J Patient Saf Risk Manag. 2019;24(1):30-36. doi:10.1177/2516043518821497. https://p…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867757/psn-pdf
    March 12, 2025 - Improving medication-related safety for residents in nursing homes: a qualitative study. March 12, 2025 Shieu B, Lee Y-W, Epps F, et al. Improving medication-related safety for residents in nursing homes: a qualitative study. J Gerontol Nurs. 2025;51(3):38-43. doi:10.3928/00989134-20250102-03. https://psnet.ahrq.g…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39349/psn-pdf
    March 23, 2011 - Promoting patient safety through prospective risk identification: example from peri-operative care. March 23, 2011 Smith AF, Boult M, Woods I, et al. Promoting patient safety through prospective risk identification: example from peri-operative care. Qual Saf Health Care. 2010;19(1):69-73. doi:10.1136/qshc.2008.0280…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36244/psn-pdf
    June 13, 2012 - With Safety in Mind: Mental Health Services and Patient Safety. June 13, 2012 Scobie S, Minghella E, Dale C, et al. London, UK: National Patient Safety Agency; 2006. https://psnet.ahrq.gov/issue/safety-mind-mental-health-services-and-patient-safety This report, the second in a series from the United Kingdom's Nati…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46051/psn-pdf
    April 12, 2017 - Automated detection of look-alike/sound-alike medication errors. April 12, 2017 Rash-Foanio C, Galanter W, Bryson M, et al. Automated detection of look-alike/sound-alike medication errors. Am J Health Syst Pharm. 2017;74(7):521-527. doi:10.2146/ajhp150690. https://psnet.ahrq.gov/issue/automated-detection-look-alik…
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