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psnet.ahrq.gov/node/41694/psn-pdf
September 19, 2012 - Effect of nonpayment for hospital-acquired,
catheter–associated urinary tract infection: a statewide
analysis.
September 19, 2012
Meddings JA, Reichert H, Rogers MAM, et al. Effect of nonpayment for hospital-acquired, catheter-
associated urinary tract infection: a statewide analysis. Ann Intern Med. 2012;157(5):3…
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psnet.ahrq.gov/node/37417/psn-pdf
March 28, 2012 - Medication use leading to emergency department visits
for adverse drug events in older adults.
March 28, 2012
Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for
adverse drug events in older adults. Ann Intern Med. 2007;147(11):755-765.
https://psnet.ahrq.gov/issue/med…
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psnet.ahrq.gov/node/38645/psn-pdf
February 15, 2011 - A comprehensive pharmacist intervention to reduce
morbidity in patients 80 years or older: a randomized
controlled trial.
February 15, 2011
Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive pharmacist intervention to reduce morbidity in
patients 80 years or older: a randomized controlled trial. Arch Inter…
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psnet.ahrq.gov/node/39139/psn-pdf
June 02, 2010 - Assessing resident safety culture in nursing homes:
using the nursing home survey on resident safety.
June 2, 2010
Castle NG, Wagner LM, Perera S, et al. Assessing Resident Safety Culture in Nursing Homes. J Patient
Saf. 2010;64(2):59-67. doi:10.1097/pts.0b013e3181bc05fc.
https://psnet.ahrq.gov/issue/assessing-res…
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psnet.ahrq.gov/node/44064/psn-pdf
November 03, 2015 - The July effect: an analysis of never events in the
nationwide inpatient sample.
November 3, 2015
Wen T, Attenello FJ, Wu B, et al. The July effect: an analysis of never events in the nationwide inpatient
sample. J Hosp Med. 2015;10(7):432-438. doi:10.1002/jhm.2352.
https://psnet.ahrq.gov/issue/july-effect-analysi…
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psnet.ahrq.gov/node/45719/psn-pdf
June 29, 2017 - Systematic review of the prevalence of medication errors
resulting in hospitalization and death of nursing home
residents.
June 29, 2017
Ferrah N, Lovell JJ, Ibrahim JE. Systematic Review of the Prevalence of Medication Errors Resulting in
Hospitalization and Death of Nursing Home Residents. J Am Geriatr Soc. 2017…
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psnet.ahrq.gov/node/39143/psn-pdf
February 14, 2011 - Impact of a pharmacist-facilitated hospital discharge
program: a quasi-experimental study.
February 14, 2011
Walker PC, Bernstein SJ, Jones JNT, et al. Impact of a pharmacist-facilitated hospital discharge program: a
quasi-experimental study. Arch Intern Med. 2009;169(21):2003-10. doi:10.1001/archinternmed.2009.398…
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psnet.ahrq.gov/node/42396/psn-pdf
July 31, 2013 - Developing and implementing a standardized process for
Global Trigger Tool application across a large health
system.
July 31, 2013
Garrett PR, Sammer C, Nelson A, et al. Developing and implementing a standardized process for global
trigger tool application across a large health system. Jt Comm J Qual Saf. 2013;39(…
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psnet.ahrq.gov/node/39730/psn-pdf
December 21, 2014 - Surgical case listing accuracy: failure analysis at a high-
volume academic medical center.
December 21, 2014
Cima RR, Hale C, Kollengode A, et al. Surgical case listing accuracy: failure analysis at a high-volume
academic medical center. Arch Surg. 2010;145(7):641-6. doi:10.1001/archsurg.2010.112.
https://psnet.a…
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psnet.ahrq.gov/node/37622/psn-pdf
May 26, 2011 - Effect of computer order entry on prevention of serious
medication errors in hospitalized children.
May 26, 2011
Walsh KE, Landrigan CP, Adams WG, et al. Effect of computer order entry on prevention of serious
medication errors in hospitalized children. Pediatrics. 2008;121(3):e421-e427. doi:10.1542/peds.2007-
022…
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psnet.ahrq.gov/node/45177/psn-pdf
June 01, 2016 - Quantifying the burden of opioid medication errors in
adult oncology and palliative care settings: a systematic
review.
June 1, 2016
Heneka N, Shaw T, Rowett D, et al. Quantifying the burden of opioid medication errors in adult oncology
and palliative care settings: A systematic review. Palliat Med. 2016;30(6):520…
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psnet.ahrq.gov/node/43224/psn-pdf
June 11, 2014 - Look alike/sound alike drugs: a literature review on
causes and solutions.
June 11, 2014
Ciociano N, Bagnasco L. Look alike/sound alike drugs: a literature review on causes and solutions. Int J
Clin Pharm. 2014;36(2):233-242. doi:10.1007/s11096-013-9885-6.
https://psnet.ahrq.gov/issue/look-alikesound-alike-drugs-l…
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psnet.ahrq.gov/node/42606/psn-pdf
September 25, 2013 - Health economic evaluation of an infection prevention
and control program: are quality and patient safety
programs worth the investment?
September 25, 2013
Raschka S, Dempster L, Bryce E. Health economic evaluation of an infection prevention and control
program: are quality and patient safety programs worth the in…
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psnet.ahrq.gov/node/46337/psn-pdf
August 30, 2017 - Nurses' response to parents' 'speaking-up' efforts to
ensure their hospitalized child's safety: an attribution
theory perspective.
August 30, 2017
Bsharat S, Drach-Zahavy A. Nurses' response to parents' 'speaking-up' efforts to ensure their hospitalized
child's safety: an attribution theory perspective. J Adv Nurs…
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psnet.ahrq.gov/node/43067/psn-pdf
November 23, 2014 - Characterization of adverse events detected in a large
health care delivery system using an enhanced Global
Trigger Tool over a five-year interval.
November 23, 2014
Kennerly DA, Kudyakov R, da Graca B, et al. Characterization of adverse events detected in a large health
care delivery system using an enhanced glob…
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psnet.ahrq.gov/node/45402/psn-pdf
November 01, 2017 - Potentially preventable 30-day hospital readmissions at a
children's hospital.
November 1, 2017
Toomey SL, Peltz A, Loren S, et al. Potentially Preventable 30-Day Hospital Readmissions at a Children's
Hospital. Pediatrics. 2016;138(2). doi:10.1542/peds.2015-4182.
https://psnet.ahrq.gov/issue/potentially-preventabl…
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psnet.ahrq.gov/node/42548/psn-pdf
December 29, 2014 - What is known about adverse events in older medical
hospital inpatients? A systematic review of the literature.
December 29, 2014
Long SJ, Brown KF, Ames D, et al. What is known about adverse events in older medical hospital
inpatients? A systematic review of the literature. Int J Health Care Qual. 2013;25(5):542-5…
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psnet.ahrq.gov/node/44374/psn-pdf
August 12, 2015 - ASHP national survey of pharmacy practice in hospital
settings: dispensing and administration—2014.
August 12, 2015
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital
settings: Dispensing and administration--2014. Am J Health Syst Pharm. 2015;72(13):1119-37.
doi:10.21…
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psnet.ahrq.gov/node/45395/psn-pdf
August 10, 2016 - Adverse inpatient outcomes during the transition to a new
electronic health record system: observational study.
August 10, 2016
Barnett ML, Mehrotra A, Jena AB. Adverse inpatient outcomes during the transition to a new electronic
health record system: observational study. BMJ. 2016;354:i3835. doi:10.1136/bmj.i3835.…
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psnet.ahrq.gov/node/47916/psn-pdf
May 29, 2019 - Incivility and patient safety: a longitudinal study of
rudeness, protocol compliance, and adverse events.
May 29, 2019
Riskin A, Bamberger P, Erez A, et al. Incivility and Patient Safety: A Longitudinal Study of Rudeness,
Protocol Compliance, and Adverse Events. Jt Comm J Qual Patient Saf. 2019;45(5):358-367.
doi:…