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psnet.ahrq.gov/node/44022/psn-pdf
May 28, 2015 - Initiatives to identify and mitigate medication errors in
England.
May 28, 2015
Cousins D, Gerrett D, Richards N, et al. Initiatives to identify and mitigate medication errors in England.
Drug Saf. 2015;38(4):349-357. doi:10.1007/s40264-015-0270-3.
https://psnet.ahrq.gov/issue/initiatives-identify-and-mitigate-med…
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psnet.ahrq.gov/node/47744/psn-pdf
July 19, 2019 - A qualitative positive deviance study to explore
exceptionally safe care on medical wards for older
people.
July 19, 2019
Baxter R, Taylor N, Kellar I, et al. A qualitative positive deviance study to explore exceptionally safe care on
medical wards for older people. BMJ Qual Saf. 2019;28(8):618-626. doi:10.1136/bm…
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psnet.ahrq.gov/node/44778/psn-pdf
July 18, 2016 - How safe is primary care? A systematic review.
July 18, 2016
Panesar SS, deSilva D, Carson-Stevens A, et al. How safe is primary care? A systematic review. BMJ Qual
Saf. 2016;25(7):544-53. doi:10.1136/bmjqs-2015-004178.
https://psnet.ahrq.gov/issue/how-safe-primary-care-systematic-review
Patient safety in ambulato…
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psnet.ahrq.gov/node/45000/psn-pdf
August 15, 2016 - Medicare and Medicaid Programs; Hospital and Critical
Access Hospital (CAH) Changes to Promote Innovation,
Flexibility, and Improvement in Patient Care; Proposed
Rule.
June 29, 2016
Centers for Medicare & Medicaid Services. Fed Regist. 2016;81:39447-39480.
https://psnet.ahrq.gov/issue/medicare-and-medicaid-progra…
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psnet.ahrq.gov/node/851065/psn-pdf
June 28, 2023 - Patient safety of perioperative medication through the
lens of digital health and artificial intelligence.
June 28, 2023
Ye J. Patient safety of perioperative medication through the lens of digital health and artificial intelligence.
JMIR Periop Med. 2023;6:e34453. doi:10.2196/34453.
https://psnet.ahrq.gov/issue/p…
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psnet.ahrq.gov/node/43377/psn-pdf
April 25, 2016 - Using Lean "automation with a human touch" to improve
medication safety: a step closer to the "perfect dose."
April 25, 2016
Ching JM, Williams BL, Idemoto LM, et al. Using lean "automation with a human touch" to improve
medication safety: a step closer to the "perfect dose". Jt Comm J Qual Patient Saf. 2014;40(8):…
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psnet.ahrq.gov/node/35220/psn-pdf
May 14, 2015 - Patient Safety and Quality Improvement Act of 2005.
May 14, 2015
Pub L No. 109-41.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005
This bill amends the Public Health Service Act to encourage a culture of safety in health care organizations.
The bill, signed into law July 29, 2005…
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psnet.ahrq.gov/node/867702/psn-pdf
September 01, 2021 - Toolkit To Reduce CAUTI and Other HAIs in Long-Term
Care Facilities.
September 1, 2021
Agency for Healthcare Research and Quality. Toolkit To Reduce CAUTI and Other HAIs in Long-Term
Care Facilities. September 2021.
https://psnet.ahrq.gov/issue/toolkit-reduce-cauti-and-other-hais-long-term-care-facilities
Cathete…
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psnet.ahrq.gov/node/864380/psn-pdf
March 13, 2024 - Stepped-wedge cluster RCT to assess the effects of an
electronic medication system on medication
administration errors.
March 13, 2024
Westbrook JI, Li L, Woods AL, et al. Stepped-wedge cluster RCT to assess the effects of an electronic
medication system on medication administration errors. Stud Health Technol Inf…
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psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
November 27, 2023 - We establish quality standards for nursing education and assist schools in implementing those standards … Students also may participate in the change process of a quality improvement committee, or in implementing
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psnet.ahrq.gov/node/44519/psn-pdf
December 02, 2015 - Drug-related-problem outcomes and program satisfaction
from a comprehensive brown bag medication review.
December 2, 2015
O'Connell MB, Chang F, Tocco A, et al. Drug-Related-Problem Outcomes and Program Satisfaction from a
Comprehensive Brown Bag Medication Review. J Am Geriatr Soc. 2015;63(9):1900-1905.
doi:10.11…
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psnet.ahrq.gov/node/46546/psn-pdf
January 10, 2018 - Using an online quiz-based reinforcement system to
teach healthcare quality and patient safety and care
transitions at the University of California.
January 10, 2018
Shaikh U, Afsar-Manesh N, Amin AN, et al. Using an online quiz-based reinforcement system to teach
healthcare quality and patient safety and care tra…
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psnet.ahrq.gov/node/45577/psn-pdf
February 08, 2017 - EHR-related medication errors in two ICUs.
February 8, 2017
Carayon P, Du S, Brown RL, et al. EHR-related medication errors in two ICUs. J Healthc Risk Manag.
2017;36(3):6-15. doi:10.1002/jhrm.21259.
https://psnet.ahrq.gov/issue/ehr-related-medication-errors-two-icus
Despite the demonstrated success of technology …
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psnet.ahrq.gov/node/44075/psn-pdf
July 16, 2015 - Physicians failed to write flawless prescriptions when
computerized physician order entry system crashed.
July 16, 2015
Hsu C-C, Chou C-L, Chen T-J, et al. Physicians Failed to Write Flawless Prescriptions When Computerized
Physician Order Entry System Crashed. Clin Ther. 2015;37(5):1076-1080.e1.
doi:10.1016/j.cli…
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psnet.ahrq.gov/node/866962/psn-pdf
October 16, 2024 - Diagnostic Excellence– Age-Friendly Health Systems
(DxEx–AFHS) Seed Grant Program Improving Diagnosis
for Older Adults.
October 16, 2024
Boston, MA: Institute for Healthcare Improvement; September 23, 2024.
https://psnet.ahrq.gov/issue/diagnostic-excellence-age-friendly-health-systems-dxex-afhs-seed-grant-
progra…
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psnet.ahrq.gov/node/44370/psn-pdf
November 20, 2015 - Interunit handoffs from emergency department to
inpatient care: a cross-sectional survey of physicians at a
university medical center.
November 20, 2015
Smith CJ, Britigan DH, Lyden E, et al. Interunit handoffs from emergency department to inpatient care: A
cross-sectional survey of physicians at a university medi…
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psnet.ahrq.gov/node/35398/psn-pdf
February 24, 2011 - Residency work-hours reform: a cost analysis including
preventable adverse events.
February 24, 2011
Nuckols TK, Escarce JJ. Residency work-hours reform. A cost analysis including preventable adverse
events. J Gen Intern Med. 2005;20(10):873-8.
https://psnet.ahrq.gov/issue/residency-work-hours-reform-cost-analysis…
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psnet.ahrq.gov/node/867381/psn-pdf
December 18, 2024 - Promoting medication safety for older adults upon
hospital discharge: guiding principles for a medication
discharge plan.
December 18, 2024
Zhang FH, Lauzon J, Payette J, et al. Promoting medication safety for older adults upon hospital discharge:
guiding principles for a medication discharge plan. Br J Clin Pharm…
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psnet.ahrq.gov/node/35134/psn-pdf
June 22, 2009 - Introduction of the medical emergency team (MET)
system: a cluster-randomised controlled trial.
June 22, 2009
Hillman K, Chen J, Cretikos M, et al. Introduction of the medical emergency team (MET) system: a cluster-
randomised controlled trial. Lancet. 2005;365(9477):2091-7.
https://psnet.ahrq.gov/issue/introducti…
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psnet.ahrq.gov/node/74028/psn-pdf
November 03, 2021 - Survey of nurses' experiences applying The Joint
Commission's medication management titration
standards.
November 3, 2021
Davidson JE, Doran N, Petty A, et al. Survey of nurses' experiences applying The Joint Commission's
medication management titration standards. Am J Crit Care. 2021;30(5):365-374.
doi:10.4037/a…