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psnet.ahrq.gov/node/42513/psn-pdf
January 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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psnet.ahrq.gov/node/37277/psn-pdf
July 28, 2010 - Drug selection errors in relation to medication labels: a
simulation study.
July 28, 2010
Garnerin P, Perneger T, Chopard P, et al. Drug selection errors in relation to medication labels: a
simulation study. Anaesthesia. 2007;62(11):1090-4.
https://psnet.ahrq.gov/issue/drug-selection-errors-relation-medication-lab…
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psnet.ahrq.gov/node/41515/psn-pdf
July 02, 2014 - Anticipated consequences of the 2011 duty hours
standards: views of internal medicine and surgery
program directors.
July 2, 2014
Shea JA, Willett LL, Borman KR, et al. Anticipated consequences of the 2011 duty hours standards: views
of internal medicine and surgery program directors. Acad Med. 2012;87(7):895-903.…
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psnet.ahrq.gov/node/60938/psn-pdf
January 23, 2020 - A model for improving health care quality for transgender
and gender nonconforming patients.
January 23, 2020
Ding JM, Ehrenfeld JM, Edmiston EK, et al. A model for improving health care quality for transgender and
gender nonconforming patients. Jt Comm J Qual Patient Saf. 2020;46(1):37-43.
doi:10.1016/j.jcjq.2019…
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psnet.ahrq.gov/node/45626/psn-pdf
October 29, 2017 - The impacts of a pharmacist-managed outpatient clinic
and chemotherapy-directed electronic order sets for
monitoring oral chemotherapy.
October 29, 2017
Battis B, Clifford L, Huq M, et al. The impacts of a pharmacist-managed outpatient clinic and
chemotherapy-directed electronic order sets for monitoring oral chem…
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psnet.ahrq.gov/node/73296/psn-pdf
May 19, 2021 - AHRQ Safety Program for Methicillin-Resistant
Staphylococcus Aureus Prevention. Request for Proposal
Comment.
May 19, 2021
Agency for Healthcare Research and Quality. May 3, 2021. Fed Register. 2021;86(83):23366-23369.
https://psnet.ahrq.gov/issue/ahrq-safety-program-methicillin-resistant-staphylococcus-aureus-pre…
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psnet.ahrq.gov/node/848082/psn-pdf
April 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…
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psnet.ahrq.gov/node/37193/psn-pdf
October 06, 2011 - Incomplete EHR adoption: late uptake of patient safety
and cost control functions.
October 6, 2011
Menachemi N, Ford E, Beitsch LM, et al. Incomplete EHR adoption: late uptake of patient safety and cost
control functions. Am J Med Qual. 2007;22(5):319-26.
https://psnet.ahrq.gov/issue/incomplete-ehr-adoption-late-u…
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psnet.ahrq.gov/node/40984/psn-pdf
September 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 …
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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/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/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/39088/psn-pdf
September 01, 2015 - Laboratory session to improve first-year pharmacy
students' knowledge and confidence concerning the
prevention of medication errors.
September 1, 2015
Kiersma ME, Darbishire PL, Plake KS, et al. Laboratory session to improve first-year pharmacy students'
knowledge and confidence concerning the prevention of medica…
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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/838128/psn-pdf
September 21, 2022 - Development of the Leapfrog Group's bar code
medication administration standard to address hospital
inpatient medication safety.
September 21, 2022
Austin JM, Bane A, Gooder V, et al. Development of the Leapfrog Group's bar code medication
administration standard to address hospital inpatient medication safety. J …
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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…