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psnet.ahrq.gov/node/41801/psn-pdf
October 31, 2012 - First year with WHO Surgical Safety Checklist in 7148
otorhinolaryngological operations: use and user
attitudes.
October 31, 2012
Helmiö P, Takala A, Aaltonen L-M, et al. First year with WHO Surgical Safety Checklist in 7148
otorhinolaryngological operations: use and user attitudes. Clin Otolaryngol. 2012;37(4):30…
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psnet.ahrq.gov/node/46266/psn-pdf
July 19, 2017 - New unintended adverse consequences of electronic
health records.
July 19, 2017
Sittig DF, Wright A, Ash J, et al. New Unintended Adverse Consequences of Electronic Health Records.
Yearb Med Inform. 2016;(1):7-12.
https://psnet.ahrq.gov/issue/new-unintended-adverse-consequences-electronic-health-records
Pressures…
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psnet.ahrq.gov/node/46114/psn-pdf
June 07, 2017 - Standardizing concentrations of adult drug infusions in
Indiana.
June 7, 2017
Walroth TA, Dossett HA, Doolin M, et al. Standardizing concentrations of adult drug infusions in Indiana.
Am J Health Syst Pharm. 2017;74(7):491-497. doi:10.2146/ajhp151018.
https://psnet.ahrq.gov/issue/standardizing-concentrations-adult…
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psnet.ahrq.gov/node/39922/psn-pdf
October 13, 2010 - What’s past is prologue: organizational learning from a
serious patient injury.
October 13, 2010
Tamuz M, Franchois KE, Thomas EJ. What’s past is prologue: Organizational learning from a serious
patient injury. Saf Sci. 2010;49(1). doi:10.1016/j.ssci.2010.06.005.
https://psnet.ahrq.gov/issue/whats-past-prologue-or…
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psnet.ahrq.gov/node/43149/psn-pdf
July 23, 2014 - FDASIA Health IT Report: Proposed Strategy and
Recommendations for a Risk-Based Framework.
July 23, 2014
Washington, DC: Office of the National Coordinator for Health Information Technology, Federal
Communications Commission. Silver Spring, MD: Food and Drug Administration. April 2014.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/41462/psn-pdf
July 03, 2016 - The use of patient pictures and verification screens to
reduce computerized provider order entry errors.
July 3, 2016
Hyman D, Laire M, Redmond D, et al. The use of patient pictures and verification screens to reduce
computerized provider order entry errors. Pediatrics. 2012;130(1):e211-9. doi:10.1542/peds.2011-298…
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psnet.ahrq.gov/node/35417/psn-pdf
February 15, 2010 - Errors in laboratory medicine: practical lessons to
improve patient safety.
February 15, 2010
Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab
Med. 2005;129(10):1252-1261.
https://psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patie…
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psnet.ahrq.gov/node/36470/psn-pdf
September 27, 2010 - Prioritizing patient safety interventions in small and rural
hospitals.
September 27, 2010
Casey M, Wakefield M, Coburn AF, et al. Prioritizing patient safety interventions in small and rural
hospitals. Jt Comm J Qual Patient Saf. 2006;32(12):693-702.
https://psnet.ahrq.gov/issue/prioritizing-patient-safety-interv…
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psnet.ahrq.gov/node/837855/psn-pdf
August 17, 2022 - Patterns of error in interpretive pathology.
August 17, 2022
Packer MDC, Ravinsky E, Azordegan N. Patterns of error in interpretive pathology. Am J Clin Pathol.
2022;157(5):767-773. doi:10.1093/ajcp/aqab190.
https://psnet.ahrq.gov/issue/patterns-error-interpretive-pathology
Studies have shown diagnostic discordanc…
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psnet.ahrq.gov/node/38839/psn-pdf
August 05, 2009 - Polypharmacy in hospitalized older adult cancer patients:
experience from a prospective, observational study of an
oncology-acute care for elders unit.
August 5, 2009
Flood KL, Carroll MB, Le C, et al. Polypharmacy in hospitalized older adult cancer patients: experience
from a prospective, observational study of…
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psnet.ahrq.gov/node/34781/psn-pdf
June 23, 2015 - Standards for patient monitoring during general
anesthesia at Harvard Medical School.
June 23, 2015
Eichhorn JH, Cooper JB, Cullen DJ, et al. Standards for patient monitoring during anesthesia at Harvard
Medical School. JAMA. 1986;256(8):1017-20.
https://psnet.ahrq.gov/issue/standards-patient-monitoring-during-gen…
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psnet.ahrq.gov/node/42489/psn-pdf
May 19, 2014 - Improving medication administration safety in solid organ
transplant patients through barcode-assisted medication
administration.
May 19, 2014
Bonkowski J, Weber RJ, Melucci J, et al. Improving medication administration safety in solid organ
transplant patients through barcode-assisted medication administration. A…
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psnet.ahrq.gov/node/45418/psn-pdf
May 09, 2017 - Context-sensitive decision support (infobuttons) in
electronic health records: a systematic review.
May 9, 2017
Cook DA, Teixeira MT, Heale BS, et al. Context-sensitive decision support (infobuttons) in electronic health
records: a systematic review. J Am Med Inform Assoc. 2017;24(2):460-468. doi:10.1093/jamia/ocw1…
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psnet.ahrq.gov/node/50558/psn-pdf
October 16, 2019 - Multidisciplinary simulation activity effectively prepares
residents for participation in patient safety activities.
October 16, 2019
Weis JJ, Croft CL, Bhoja R, et al. Multidisciplinary simulation activity effectively prepares residents for
participation in patient safety activities. J Surg Educ. 2019;76(6):e232-e…
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psnet.ahrq.gov/node/35216/psn-pdf
December 22, 2009 - An educational intervention to enhance nurse leaders'
perceptions of patient safety culture.
December 22, 2009
Ginsburg LR, Norton PG, Casebeer A, et al. An educational intervention to enhance nurse leaders'
perceptions of patient safety culture. Health Serv Res. 2005;40(4):997-1020.
https://psnet.ahrq.gov/issue/e…
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psnet.ahrq.gov/node/34868/psn-pdf
February 03, 2011 - Role of computerized physician order entry systems in
facilitating medication errors.
February 3, 2011
Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating
medication errors. JAMA. 2005;293(10):1197-203.
https://psnet.ahrq.gov/issue/role-computerized-physician-ord…
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psnet.ahrq.gov/node/841785/psn-pdf
December 21, 2022 - Request for Information: Creating a National Healthcare
System Action Alliance to Advance Patient Safety.
December 21, 2022
Agency for Healthcare Research and Quality. Fed Register. December 12, 2022;87:76046-76048.
https://psnet.ahrq.gov/issue/request-information-creating-national-healthcare-system-action-alliance…
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psnet.ahrq.gov/node/43498/psn-pdf
October 06, 2016 - Creating a distraction simulation for safe medication
administration.
October 6, 2016
Thomas CM, McIntosh CE, Allen R. Creating a Distraction Simulation for Safe Medication Administration.
Clin Simul Nurs. 2014;10(8). doi:10.1016/j.ecns.2014.03.004.
https://psnet.ahrq.gov/issue/creating-distraction-simulation-safe…
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psnet.ahrq.gov/node/46403/psn-pdf
September 06, 2017 - Supplemental Issue: Quality and Safety Education for
Nurses (QSEN) program.
September 6, 2017
Quality and Safety Education for Nurses.
https://psnet.ahrq.gov/issue/supplemental-issue-quality-and-safety-education-nurses-qsen-program
Patient safety and quality improvement competencies are developed through interprof…
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psnet.ahrq.gov/node/44465/psn-pdf
November 20, 2015 - Why even good physicians do not wash their hands.
November 20, 2015
Redelmeier DA, Shafir E. Why even good physicians do not wash their hands. BMJ Qual Saf.
2015;24(12):744-7. doi:10.1136/bmjqs-2015-004319.
https://psnet.ahrq.gov/issue/why-even-good-physicians-do-not-wash-their-hands
Insufficient hand hygiene comp…