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psnet.ahrq.gov/node/864861/psn-pdf
September 19, 2022 - Should audits consider the care pathway model? A new
approach to benchmarking real-world activities.
September 19, 2022
Kwok CS, Waters D, Phan T, et al. Should audits consider the care pathway model? A new approach to
benchmarking real-world activities. Healthcare. 2022;10(9):1798. doi:10.3390/healthcare10091798.
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psnet.ahrq.gov/node/850172/psn-pdf
June 07, 2023 - Clinical nurse competence and its effect on patient safety
culture: a systematic review.
June 7, 2023
Zaitoun RA, Said NB, de Tantillo L. Clinical nurse competence and its effect on patient safety culture: a
systematic review. BMC Nurs. 2023;22(1):173. doi:10.1186/s12912-023-01305-w.
https://psnet.ahrq.gov/issue/c…
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psnet.ahrq.gov/node/74758/psn-pdf
February 09, 2022 - Emotional harm in the radiology department: analysis of
an underrecognized preventable error.
February 9, 2022
Siewert B, Swedeen S, Brook OR, et al. Emotional harm in the radiology department: analysis of an
underrecognized preventable error. Radiology. 2022;302(3):613-619. doi:10.1148/radiol.2021211846.
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psnet.ahrq.gov/node/34673/psn-pdf
December 23, 2008 - Relationship between medication errors and adverse drug
events.
December 23, 2008
Bates DW, Boyle DL, Vliet MBV, et al. Relationship between medication errors and adverse drug events. J
Gen Intern Med. 1995;10(4):199-205.
https://psnet.ahrq.gov/issue/relationship-between-medication-errors-and-adverse-drug-events
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psnet.ahrq.gov/node/73494/psn-pdf
July 14, 2021 - A scoping review of communication tools applicable to
patients and their primary care providers after discharge
from hospital.
July 14, 2021
Spencer RA, Singh Punia H. A scoping review of communication tools applicable to patients and their
primary care providers after discharge from hospital. Patient Educ Couns. …
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psnet.ahrq.gov/node/34639/psn-pdf
March 02, 2011 - Preventable deaths: who, how often, and why?
March 2, 2011
Dubois RW, Brook RH. Preventable deaths: who, how often, and why? Ann Intern Med. 1988;109(7):582-9.
https://psnet.ahrq.gov/issue/preventable-deaths-who-how-often-and-why
One of the first studies to examine the link between quality of care and hospital deat…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/148-investigating-defect-lfd-worksheet.docx
June 02, 2025 - AHRQ Safety Program for MRSA Prevention
Investigating A Defect Worksheet
ICU & Non-ICUTop Contributing Factors
Interventions To Reduce Risk
Who Will Do It and By When
Status
Enter contributing factor
Enter intervention
Enter responsible staff, deadline
Enter status
Enter contributing factor
Enter intervention
Enter re…
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psnet.ahrq.gov/node/861277/psn-pdf
January 24, 2024 - Clinical deterioration as a nurse sensitive indicator in the
out-of-hospital context: a scoping review.
January 24, 2024
Mccullough K, Baker M, Bloxsome D, et al. Clinical deterioration as a nurse sensitive indicator in the out?of
?hospital context: a scoping review. J Clin Nurs. 2024;33(3):874-889. doi:10.1111/joc…
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psnet.ahrq.gov/node/837765/psn-pdf
August 03, 2022 - Pediatric musculoskeletal radiographs: anatomy and
fractures prone to diagnostic error among emergency
physicians.
August 3, 2022
Li W, Stimec J, Camp M, et al. Pediatric musculoskeletal radiographs: anatomy and fractures prone to
diagnostic error among emergency physicians. J Emerg Med. 2022;62(4):524-533.
doi:1…
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psnet.ahrq.gov/node/48076/psn-pdf
July 24, 2019 - Simulation-based event analysis improves error
discovery and generates improved strategies for error
prevention.
July 24, 2019
Lobos A-T, Ward N, Farion KJ, et al. Simulation-based event analysis improves error discovery and
generates improved strategies for error prevention. Simul Healthc. 2019;14(4):209-216.
do…
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psnet.ahrq.gov/node/50630/psn-pdf
November 06, 2019 - Non-dispensing pharmacists' actions and solutions of
drug therapy problems among elderly polypharmacy
patients in primary care.
November 6, 2019
Hazen ACM, Zwart DLM, Poldervaart JM, et al. Non-dispensing pharmacists' actions and solutions of drug
therapy problems among elderly polypharmacy patients in primary car…
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psnet.ahrq.gov/node/847725/psn-pdf
April 19, 2023 - A scoping review of the hidden curriculum in pharmacy
education.
April 19, 2023
Park SK, Chen AMH, Daugherty KK, et al. A scoping review of the hidden curriculum in pharmacy
education. Am J Pharm Educ. 2023;87(3):ajpe8999. doi:10.5688/ajpe8999.
https://psnet.ahrq.gov/issue/scoping-review-hidden-curriculum-pharmacy…
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psnet.ahrq.gov/node/60955/psn-pdf
September 30, 2020 - The emergency department trigger tool: a novel approach
to screening for quality and safety events.
September 30, 2020
Griffey RT, Schneider RM, Todorov AA. The emergency department trigger tool: a novel approach to
screening for quality and safety events. Ann Emerg Med. 2020;76(2):230-240.
doi:10.1016/j.annemergm…
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psnet.ahrq.gov/node/849605/psn-pdf
May 31, 2023 - Identification of patient safety threats in a post-intensive
care clinic.
May 31, 2023
Karlic KJ, Valley TS, Cagino LM, et al. Identification of patient safety threats in a post-intensive care clinic.
Am J Med Qual. 2023;38(3):117-121. doi:10.1097/jmq.0000000000000118.
https://psnet.ahrq.gov/issue/identification-p…
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psnet.ahrq.gov/node/852753/psn-pdf
August 23, 2023 - Status of patient safety culture in community pharmacy
settings: a systematic review.
August 23, 2023
Kwon K-E, Nam DR, Lee M-S, et al. Status of patient safety culture in community pharmacy settings: a
systematic review. J Patient Saf. 2023;19(6):353-361. doi:10.1097/pts.0000000000001147.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/845347/psn-pdf
March 01, 2023 - Race differences in a malpractice event database in a
large healthcare system.
March 1, 2023
Thomas AD, Pandit C, Krevat S. Race differences in a malpractice event database in a large healthcare
system. J Patient Saf. 2023;19(2):67-70. doi:10.1097/pts.0000000000001090.
https://psnet.ahrq.gov/issue/race-differences…
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psnet.ahrq.gov/node/73186/psn-pdf
April 28, 2021 - Inappropriate dosing of direct oral anticoagulants in
patients with atrial fibrillation.
April 28, 2021
Sugrue A, Sanborn D, Amin M, et al. Inappropriate dosing of direct oral anticoagulants in patients with atrial
fibrillation. Am J Cardiol. 2020;144:52-59. doi:10.1016/j.amjcard.2020.12.062.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/74084/psn-pdf
November 17, 2021 - Healthcare failure mode and effect analysis in the
chemotherapy preparation process.
November 17, 2021
Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. Healthcare failure mode and effect
analysis in the chemotherapy preparation process. J Oncol Pharm Pract. 2021;27(7):1588-1595.
doi:10.1177/107815522…
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psnet.ahrq.gov/node/47568/psn-pdf
March 06, 2019 - Trends in anesthesia-related liability and lessons learned.
March 6, 2019
Mora JC, Kaye AD, Romankowski ML, et al. Trends in Anesthesia-Related Liability and Lessons Learned.
Adv Anesth. 2018;36(1):231-249. doi:10.1016/j.aan.2018.07.009.
https://psnet.ahrq.gov/issue/trends-anesthesia-related-liability-and-lessons-l…
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psnet.ahrq.gov/node/863760/psn-pdf
March 06, 2024 - Imagining improved interactions: patients' designs to
address implicit bias.
March 6, 2024
Yang C, Coney L, Mohanraj D, et al. AMIA Annu Symp Proc. 2023;2023:774-783.
https://psnet.ahrq.gov/issue/imagining-improved-interactions-patients-designs-address-implicit-bias
Implicit biases can compromise decision making a…