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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41606/psn-pdfFebruary 01, 2019 - Safe use of opioids in hospitals. December 23, 2016 Sentinel Event Alert. 2012;49:1-5. https://psnet.ahrq.gov/issue/safe-use-opioids-hospitals Opioid pain medications are considered high-risk medications due to the potential for respiratory depression and other adverse effects. Because these medications are freque… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44579/psn-pdfSeptember 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… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46094/psn-pdfJuly 11, 2017 - Hiding in plain sight—resurrecting the power of inspecting the patient. July 11, 2017 Gupta S, Saint S, Detsky AS. Hiding in Plain Sight-Resurrecting the Power of Inspecting the Patient. JAMA Intern Med. 2017;177(6):757-758. doi:10.1001/jamainternmed.2017.0634. https://psnet.ahrq.gov/issue/hiding-plain-sight-resur… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45031/psn-pdfFebruary 18, 2017 - Information transfer in multidisciplinary operating room teams: a simulation-based observational study. February 18, 2017 Cumin D, Skilton C, Weller J. Information transfer in multidisciplinary operating room teams: a simulation- based observational study. BMJ Qual Saf. 2017;26(3):209-216. doi:10.1136/bmjqs-2015-00… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837597/psn-pdfJune 29, 2022 - Patient safety informatics: criteria development for assessing the maturity of digital patient safety in hospitals. June 29, 2022 Kutza J-O, Hübner U, Holmgren AJ, et al. Patient safety informatics: criteria development for assessing the maturity of digital patient safety in hospitals. Stud Health Technol Inform. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/867097/psn-pdfNovember 06, 2024 - Recommendations but no Action: Improving the Effectiveness of Quality and Safety Recommendations in Healthcare. November 6, 2024 Recommendations But No Action: Improving The Effectiveness Of Quality And Safety Recommendations In Healthcare. Dorset, UK: Health Services Safety Investigations Body; September 2024. h… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/848082/psn-pdfApril 26, 2023 - Adopting high reliability organization principles to lead a large scale clinical transformation. April 26, 2023 Pozzobon LD, Lam J, Chimonides E, et al. Adopting high reliability organization principles to lead a large scale clinical transformation. Healthc Manage Forum. 2023;36(4):241-245. doi:10.1177/08404704231… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47990/psn-pdfJune 18, 2019 - The admission conference call: a novel approach to optimizing pediatric emergency department to admitting floor communication. June 18, 2019 Hendrickson MA, Schempf EN, Furnival RA, et al. The Admission Conference Call: A Novel Approach to Optimizing Pediatric Emergency Department to Admitting Floor Communication.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42885/psn-pdfJanuary 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… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45868/psn-pdfJanuary 31, 2018 - Increasing trainee reporting of adverse events with monthly, trainee-directed review of adverse events. January 31, 2018 Smith A, Hatoun J, Moses J. Increasing Trainee Reporting of Adverse Events With Monthly Trainee- Directed Review of Adverse Events. Acad Pediatr. 2017;17(8):902-906. doi:10.1016/j.acap.2017.01.00… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44748/psn-pdfAugust 19, 2016 - Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clinical and managerial priorities. August 19, 2016 Pannick S, Sevdalis N, Athanasiou T. Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clinical and managerial priorities. BM… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/854255/psn-pdfOctober 04, 2023 - Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival. October 4, 2023 McCoy C, Keshvani N, Warsi M, et al. Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival. BMJ Open Qual. 2023;12(3):e002220. doi:10.11… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44877/psn-pdfApril 27, 2016 - Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices. April 27, 2016 Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16- 158. https://psnet.ahrq.gov/issue/actions-needed-help-ensure-appropriate-medication-continuation-and- pre… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46815/psn-pdfApril 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 … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43783/psn-pdfJanuary 14, 2015 - Improving the quality and safety of care on the medical ward: a review and synthesis of the evidence base. January 14, 2015 Pannick S, Beveridge I, Wachter R, et al. Improving the quality and safety of care on the medical ward: A review and synthesis of the evidence base. Eur J Intern Med. 2014;25(10):874-87. doi:… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40984/psn-pdfSeptember 01, 2016 - Provider and pharmacist responses to warfarin drug–drug interaction alerts: a study of healthcare downstream of CPOE alerts. September 1, 2016 Miller AM, Boro MS, Korman NE, et al. Provider and pharmacist responses to warfarin drug-drug interaction alerts: a study of healthcare downstream of CPOE alerts. J Am Med … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/34803/psn-pdfJanuary 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… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866855/psn-pdfOctober 02, 2024 - Reduction in preventable time-critical dose omissions: impact of electronic medication management systems on in-patients. October 2, 2024 Graudins LV, Crute S, Poole SG, et al. Reduction in preventable time-critical dose omissions: impact of electronic medication management systems on in-patients. Contemp Nurse. 2… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35850/psn-pdfMay 27, 2011 - Computerization can create safety hazards: a bar-coding near miss. May 27, 2011 McDonald CJ. Computerization can create safety hazards: a bar-coding near miss. Ann Intern Med. 2006;144(7):510-6. https://psnet.ahrq.gov/issue/computerization-can-create-safety-hazards-bar-coding-near-miss This case study shares the … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42513/psn-pdfJanuary 15, 2014 - A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality. January 15, 2014 Brilli RJ, McClead RE, Crandall W, et al. A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality. J Pediat…
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