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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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/…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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 …
  15. Psn-Pdf (pdf file)

    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 …
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…

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