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psnet.ahrq.gov/node/42758/psn-pdf
October 17, 2016 - Suffering in silence: a qualitative study of second victims
of adverse events.
October 17, 2016
Ullström S, Sachs MA, Hansson J, et al. Suffering in silence: a qualitative study of second victims of
adverse events. BMJ Qual Saf. 2014;23(4):325-331. doi:10.1136/bmjqs-2013-002035.
https://psnet.ahrq.gov/issue/suffer…
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psnet.ahrq.gov/node/45535/psn-pdf
January 23, 2017 - Surgical specimen management: a descriptive study of
648 adverse events and near misses.
January 23, 2017
Steelman VM, Williams TL, Szekendi MK, et al. Surgical specimen management: a descriptive study of 648
adverse events and near misses. Arch Pathol Lab Med. 2016;140(12):1390-1396.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/38964/psn-pdf
November 27, 2009 - Development of a measure of patient safety event
learning responses.
November 27, 2009
Ginsburg LR, Chuang Y-T, Norton PG, et al. Development of a measure of patient safety event learning
responses. Health Serv Res. 2009;44(6):2123-47. doi:10.1111/j.1475-6773.2009.01021.x.
https://psnet.ahrq.gov/issue/development-…
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psnet.ahrq.gov/node/844040/psn-pdf
February 08, 2023 - A customized triggers program: a children's hospital's
experience in improving trigger usability.
February 8, 2023
Reinhart RM, Safari-Ferra P, Badh R, et al. A customized triggers program: a children's hospital's
experience in improving trigger usability. Pediatrics. 2023;151(2):e2022056452. doi:10.1542/peds.2022-…
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psnet.ahrq.gov/node/44558/psn-pdf
April 25, 2016 - Using voluntary reports from physicians to learn from
diagnostic errors in emergency medicine.
April 25, 2016
Okafor N, Payne VL, Chathampally Y, et al. Using voluntary reports from physicians to learn from
diagnostic errors in emergency medicine. Emerg Med J. 2016;33(4):245-252. doi:10.1136/emermed-2014-
204604.
…
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psnet.ahrq.gov/node/43679/psn-pdf
May 22, 2015 - Patient safety goals for the proposed Federal Health
Information Technology Safety Center.
May 22, 2015
Sittig DF, Classen D, Singh H. Patient safety goals for the proposed Federal Health Information
Technology Safety Center. J Am Med Inform Assoc. 2015;22(2):472-8. doi:10.1136/amiajnl-2014-002988.
https://psnet.a…
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psnet.ahrq.gov/node/46283/psn-pdf
April 24, 2018 - Decreasing prescribing errors during pediatric
emergencies: a randomized simulation trial.
April 24, 2018
Larose G, Levy A, Bailey B, et al. Decreasing Prescribing Errors During Pediatric Emergencies: A
Randomized Simulation Trial. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-3200.
https://psnet.ahrq.gov/issue/d…
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psnet.ahrq.gov/node/39402/psn-pdf
August 08, 2010 - The quest to eliminate intrathecal vincristine errors: a 40-
year journey.
August 8, 2010
Noble DJ, Donaldson LJ. The quest to eliminate intrathecal vincristine errors: a 40-year journey. Qual Saf
Health Care. 2010;19(4):323-326. doi:10.1136/qshc.2008.030874.
https://psnet.ahrq.gov/issue/quest-eliminate-intratheca…
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psnet.ahrq.gov/node/42721/psn-pdf
December 12, 2014 - Infusional chemotherapy and medication errors in a
tertiary care pediatric cancer unit in a resource-limited
setting.
December 12, 2014
Dhamija M, Kapoor G, Juneja A. Infusional chemotherapy and medication errors in a tertiary care pediatric
cancer unit in a resource-limited setting. J Pediatr Hematol Oncol. 2014;…
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psnet.ahrq.gov/node/37546/psn-pdf
June 14, 2011 - Effective interventions and implementation strategies to
reduce adverse drug events in the Veterans Affairs (VA)
system.
June 14, 2011
Mills PD, Neily J, Kinney LM, et al. Effective interventions and implementation strategies to reduce adverse
drug events in the Veterans Affairs (VA) system. Qual Saf Health Care. …
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psnet.ahrq.gov/node/43190/psn-pdf
September 04, 2015 - Pediatric obesity and safety in inpatient settings: a
systematic literature review.
September 4, 2015
Halvorson EE, Irby MB, Skelton JA. Pediatric obesity and safety in inpatient settings: a systematic literature
review. Clin Pediatr (Phila). 2014;53(10):975-87. doi:10.1177/0009922814533406.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/44453/psn-pdf
June 21, 2016 - Inadequacies of physical examination as a cause of
medical errors and adverse events: a collection of
vignettes.
June 21, 2016
Verghese A, Charlton B, Kassirer JP, et al. Inadequacies of Physical Examination as a Cause of Medical
Errors and Adverse Events: A Collection of Vignettes. Am J Med. 2015;128(12):1322-4.e…
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psnet.ahrq.gov/node/44497/psn-pdf
September 09, 2015 - VA Health Care: Actions Needed to Assess Decrease in
Root Cause Analyses of Adverse Events.
September 9, 2015
Washington, DC: United States Government Accountability Office; July 29, 2015. Publication GAO-15-643.
https://psnet.ahrq.gov/issue/va-health-care-actions-needed-assess-decrease-root-cause-analyses-
advers…
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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