-
psnet.ahrq.gov/node/73110/psn-pdf
April 07, 2021 - Does one size fit all? Assessing the need for
organizational second victim support programs.
April 7, 2021
Edrees HH, Wu AW. Does one size fit all? Assessing the need for organizational second victim support
programs. J Patient Saf. 2021;17(3):e247-e254. doi:10.1097/pts.0000000000000321.
https://psnet.ahrq.gov/iss…
-
psnet.ahrq.gov/node/44963/psn-pdf
January 23, 2017 - The frequency of intravenous medication administration
errors related to smart infusion pumps: a multihospital
observational study.
January 23, 2017
Schnock KO, Dykes PC, Albert J, et al. The frequency of intravenous medication administration errors
related to smart infusion pumps: a multihospital observational st…
-
psnet.ahrq.gov/node/44626/psn-pdf
November 04, 2015 - "SWARMing" to improve patient care: a novel approach to
root cause analysis.
November 4, 2015
Li J, Boulanger B, Norton J, et al. "SWARMing" to Improve Patient Care: A Novel Approach to Root Cause
Analysis. Jt Comm J Qual Patient Saf. 2015;41(11):494-501.
https://psnet.ahrq.gov/issue/swarming-improve-patient-care-…
-
psnet.ahrq.gov/node/60023/psn-pdf
March 11, 2020 - Patient-related factors associated with an increased risk
of being a reported case of preventable harm in first-line
health care: a case-control study
March 11, 2020
Fernholm R, Holzmann MJ, Wachtler C, et al. Patient-related factors associated with an increased risk of
being a reported case of preventable harm in…
-
psnet.ahrq.gov/node/837424/psn-pdf
June 15, 2022 - Allergy safety events in healthcare: development and
application of a classification schema based on
retrospective review.
June 15, 2022
Phadke NA, Wickner PG, Wang L, et al. Allergy safety events in healthcare: development and application
of a classification schema based on retrospective review. J Allergy Clin Im…
-
psnet.ahrq.gov/node/46197/psn-pdf
September 24, 2017 - Implementation and evaluation of a prototype consumer
reporting system for patient safety events.
September 24, 2017
Weingart SN, Weissman JS, Zimmer KP, et al. Implementation and evaluation of a prototype consumer
reporting system for patient safety events. Int J Qual Health Care. 2017;29(4):521-526.
doi:10.1093/…
-
psnet.ahrq.gov/node/47516/psn-pdf
December 19, 2018 - Patient groups, clinicians and healthcare professionals
agree—all test results need to be seen, understood and
followed up.
December 19, 2018
Dahm MR, Georgiou A, Herkes R, et al. Patient groups, clinicians and healthcare professionals agree - all
test results need to be seen, understood and followed up. Diagnosis…
-
psnet.ahrq.gov/node/45055/psn-pdf
December 04, 2016 - Analysis of clinical decision support system
malfunctions: a case series and survey.
December 4, 2016
Wright A, Hickman T-TT, McEvoy D, et al. Analysis of clinical decision support system malfunctions: a case
series and survey. J Am Med Inform Assoc. 2016;23(6):1068-1076. doi:10.1093/jamia/ocw005.
https://psnet.ah…
-
psnet.ahrq.gov/node/46565/psn-pdf
January 23, 2019 - Closing the Loop: A Guide to Safer Ambulatory Referrals
in the EHR Era.
January 23, 2019
Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for
Healthcare Improvement; 2017.
https://psnet.ahrq.gov/issue/closing-loop-guide-safer-ambulatory-referrals-ehr-era
Missed an…
-
psnet.ahrq.gov/node/40341/psn-pdf
November 30, 2016 - Hospital Survey on Patient Safety Culture: 2011 User
Comparative Database Report.
November 30, 2016
Sorra J, Famolaro T, Dyer N, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2011.
AHRQ Publication No. 11-0030.
https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2011-user-…
-
psnet.ahrq.gov/periodic-issue/periodic-issue-329
February 23, 2022 - Study
Preventable adverse events in obstetrics: systemic assessment of their incidence … Study
Preventable adverse events in obstetrics: systemic assessment of their incidence
-
psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - Incidence of adverse events and negligence in hospitalized patients. … Incidence and types of adverse events and negligent care in Utah and Colorado.
-
digital.ahrq.gov/sites/default/files/docs/page/09-0023-EF_bcma_0.pdf
December 01, 2008 - Incidence of adverse events and negligence in hospitalized
patients: results from the Harvard Medical … Incidence of adverse drug events and potential adverse drug events.
JAMA 1995;274:29-34.
6. … Effect of bar-code technology on the incidence of medication
dispensing errors and potential adverse
-
www.cahps.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-135-graphics-section-5.pdf
November 26, 2013 - initiation of penicillin prophylaxis
for children with SCD under age 5 years
significantly reduced the incidence … daily administration of oral penicillin reduced Prophylaxis with oral
the incidence of life-threatening … The study was ended early
because of an 84% reduction in incidence of
Engl J Med
1986;314(25):1593
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-135-graphics-section-5.pdf
November 26, 2013 - initiation of penicillin prophylaxis
for children with SCD under age 5 years
significantly reduced the incidence … daily administration of oral penicillin reduced Prophylaxis with oral
the incidence of life-threatening … The study was ended early
because of an 84% reduction in incidence of
Engl J Med
1986;314(25):1593
-
www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-135-graphics-section-5.pdf
November 26, 2013 - initiation of penicillin prophylaxis
for children with SCD under age 5 years
significantly reduced the incidence … daily administration of oral penicillin reduced Prophylaxis with oral
the incidence of life-threatening … The study was ended early
because of an 84% reduction in incidence of
Engl J Med
1986;314(25):1593
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-135-graphics-section-5.pdf
November 26, 2013 - initiation of penicillin prophylaxis
for children with SCD under age 5 years
significantly reduced the incidence … daily administration of oral penicillin reduced Prophylaxis with oral
the incidence of life-threatening … The study was ended early
because of an 84% reduction in incidence of
Engl J Med
1986;314(25):1593
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-135-graphics-section-5.pdf
November 26, 2013 - initiation of penicillin prophylaxis
for children with SCD under age 5 years
significantly reduced the incidence … daily administration of oral penicillin reduced Prophylaxis with oral
the incidence of life-threatening … The study was ended early
because of an 84% reduction in incidence of
Engl J Med
1986;314(25):1593
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-135-graphics-section-5.pdf
November 26, 2013 - initiation of penicillin prophylaxis
for children with SCD under age 5 years
significantly reduced the incidence … daily administration of oral penicillin reduced Prophylaxis with oral
the incidence of life-threatening … The study was ended early
because of an 84% reduction in incidence of
Engl J Med
1986;314(25):1593
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-135-graphics-section-5.pdf
November 26, 2013 - initiation of penicillin prophylaxis
for children with SCD under age 5 years
significantly reduced the incidence … daily administration of oral penicillin reduced Prophylaxis with oral
the incidence of life-threatening … The study was ended early
because of an 84% reduction in incidence of
Engl J Med
1986;314(25):1593