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psnet.ahrq.gov/node/837801/psn-pdf
August 10, 2022 - Decreasing misdiagnoses of urinary tract infections in a
pediatric emergency department.
August 10, 2022
Ostrow O, Prodanuk M, Foong Y, et al. Decreasing misdiagnoses of urinary tract infections in a pediatric
emergency department. Pediatrics. 2022;150(1):e2021055866. doi:10.1542/peds.2021-055866.
https://psnet.ah…
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psnet.ahrq.gov/node/866728/psn-pdf
September 18, 2024 - ROI for a fall prevention intervention: invest a little, save a
lot.
September 18, 2024
Cooper AS. ROI for a fall prevention intervention: invest a little, save a lot. Nurs Adm Q. 2024;48(3):248-
252. doi:10.1097/naq.0000000000000647.
https://psnet.ahrq.gov/issue/roi-fall-prevention-intervention-invest-little-save…
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psnet.ahrq.gov/node/44493/psn-pdf
September 19, 2016 - Interventions in health organisations to reduce the impact
of adverse events in second and third victims.
September 19, 2016
Mira JJ, Lorenzo S, Carrillo I, et al. Interventions in health organisations to reduce the impact of adverse
events in second and third victims. BMC Health Serv Res. 2015;15:341. doi:10.1186/…
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psnet.ahrq.gov/node/47024/psn-pdf
November 28, 2018 - FDA Safety Communication: use caution with implanted
pumps for intrathecal administration of medicines for
pain management.
November 28, 2018
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 14, 2018.
https://psnet.ahrq.gov/issue/fda-safety-communication-use-caution-implanted-pum…
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psnet.ahrq.gov/node/34803/psn-pdf
January 05, 2017 - Systematic root cause analysis of adverse drug events in
a tertiary referral hospital.
January 5, 2017
Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary
Referral Hospital. Jt Comm J Qual Improv. 2016;26(10). doi:10.1016/s1070-3241(00)26048-3.
https://psnet.ah…
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psnet.ahrq.gov/node/43805/psn-pdf
February 11, 2015 - Understanding the nature of medication errors in an ICU
with a computerized physician order entry system.
February 11, 2015
Cho IS, Park H, Choi YJ, et al. Understanding the nature of medication errors in an ICU with a
computerized physician order entry system. PLoS One. 2014;9(12):e114243.
doi:10.1371/journal.pon…
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psnet.ahrq.gov/node/47595/psn-pdf
March 06, 2019 - Approaches and Challenges to Electronically Matching
Patients' Records Across Providers.
March 6, 2019
Washington, DC: United States Government Accountability Office; January 2019. Publication GAO-19-197.
https://psnet.ahrq.gov/issue/approaches-and-challenges-electronically-matching-patients-records-across-
provid…
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psnet.ahrq.gov/node/44579/psn-pdf
September 01, 2016 - Increased appropriateness of customized alert
acknowledgement reasons for overridden medication
alerts in a computerized provider order entry system.
September 1, 2016
Dekarske BM, Zimmerman CR, Chang R, et al. Increased appropriateness of customized alert
acknowledgement reasons for overridden medication alerts i…
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psnet.ahrq.gov/node/40427/psn-pdf
May 04, 2011 - Development of a tool within the electronic medical
record to facilitate medication reconciliation after hospital
discharge.
May 4, 2011
Schnipper JL, Liang CL, Hamann C, et al. Development of a tool within the electronic medical record to
facilitate medication reconciliation after hospital discharge. J Am Med Inf…
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psnet.ahrq.gov/node/866958/psn-pdf
October 16, 2024 - Beyond error: a qualitative study of human factors in
serious adverse events.
October 16, 2024
Mujuru C, Peisah C. Beyond error: a qualitative study of human factors in serious adverse events. J
Healthc Risk Manag. 2024;44(2):7-13. doi:10.1002/jhrm.21583.
https://psnet.ahrq.gov/issue/beyond-error-qualitative-study…
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psnet.ahrq.gov/node/35159/psn-pdf
January 02, 2017 - Medication reconciliation in acute care: ensuring an
accurate drug regimen on admission and discharge.
January 2, 2017
Rodehaver C, Fearing D. Medication reconciliation in acute care: ensuring an accurate drug regimen on
admission and discharge. Jt Comm J Qual Patient Saf. 2005;31(7):406-13.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/48018/psn-pdf
July 31, 2019 - PEARLS for systems integration: a modified PEARLS
framework for debriefing systems-focused simulations.
July 31, 2019
Dubé MM, Reid J, Kaba A, et al. PEARLS for Systems Integration: A Modified PEARLS Framework for
Debriefing Systems-Focused Simulations. Simul Healthc. 2019;14(5):333-342.
doi:10.1097/SIH.0000000000…
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psnet.ahrq.gov/node/47186/psn-pdf
October 24, 2018 - Quality, Value, and Patient Safety in Orthopedic Surgery.
October 24, 2018
Azar FM, ed. Orthop Clin North Am. 2018;49(4):A1-A8,389-552.
https://psnet.ahrq.gov/issue/quality-value-and-patient-safety-orthopedic-surgery
Quality and value have intersecting influence on the safety of health care. Articles in this specia…
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psnet.ahrq.gov/node/46815/psn-pdf
April 29, 2018 - Designing and evaluating an automated system for real-
time medication administration error detection in a
neonatal intensive care unit.
April 29, 2018
Ni Y, Lingren T, Hall ES, et al. Designing and evaluating an automated system for real-time medication
administration error detection in a neonatal intensive care …
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psnet.ahrq.gov/node/43516/psn-pdf
June 15, 2017 - Application of failure mode effect analysis to improve the
care of septic patients admitted through the emergency
department.
June 15, 2017
Alamry A, Owais SMA, Marini AM, et al. Application of Failure Mode Effect Analysis to Improve the Care of
Septic Patients Admitted Through the Emergency Department. J Patient …
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psnet.ahrq.gov/node/42885/psn-pdf
January 22, 2014 - Medication error reporting in rural critical access
hospitals in the North Dakota Telepharmacy Project.
January 22, 2014
Scott DM, Friesner DL, Rathke AM, et al. Medication error reporting in rural critical access hospitals in the
North Dakota Telepharmacy Project. Am J Health Syst Pharm. 2014;71(1):58-67. doi:10.2…
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psnet.ahrq.gov/node/72569/psn-pdf
January 01, 2021 - Risk factors associated with medication ordering errors.
December 16, 2020
Abraham J, Galanter WL, Touchette DR, et al. Risk factors associated with medication ordering errors. J
Am Med Inform Assoc. 2021;18(1):86-94. doi:10.1093/jamia/ocaa264.
https://psnet.ahrq.gov/issue/risk-factors-associated-medication-orderin…
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psnet.ahrq.gov/node/44952/psn-pdf
March 02, 2016 - Engaging pediatric resident physicians in quality
improvement through resident-led morbidity and mortality
conferences.
March 2, 2016
Destino LA, Kahana M, Patel SJ. Engaging Pediatric Resident Physicians in Quality Improvement Through
Resident-Led Morbidity and Mortality Conferences. Jt Comm J Qual Patient Saf. 2…
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psnet.ahrq.gov/node/837068/psn-pdf
May 11, 2022 - Barriers and enablers to nurses' use of harm prevention
strategies for older patients in hospital: a cross-sectional
survey.
May 11, 2022
Redley B, Taylor N, Hutchinson A. Barriers and enablers to nurses' use of harm prevention strategies for
older patients in hospital: a cross?sectional survey. J Adv Nurs. 2022;7…
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psnet.ahrq.gov/node/43693/psn-pdf
January 20, 2015 - Effectiveness of facilitated introduction of a standard
operating procedure into routine processes in the
operating theatre: a controlled interrupted time series.
January 20, 2015
Morgan L, New S, Robertson ER, et al. Effectiveness of facilitated introduction of a standard operating
procedure into routine processe…