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psnet.ahrq.gov/issue/what-every-health-care-organization-should-know-about-sentinel-events
November 27, 2018 - The text includes a sample sentinel event root cause analysis form and a glossary.
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psnet.ahrq.gov/issue/forgive-and-remember-managing-medical-failure-2nd-ed
March 27, 2005 - This edition, published more than two decades after Forgive and Remember was first published, includes
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psnet.ahrq.gov/issue/ahrq-safety-program-end-stage-renal-disease-facilities-toolkit
December 24, 2008 - Building on evidence and insights from clinicians, this four-part toolkit includes videos, assessment
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psnet.ahrq.gov/issue/medication-related-adverse-outcomes-us-hospitals-and-emergency-departments-2008
September 15, 2010 - Utilization Project , this report updates a 2004 analysis of medication-related adverse events and includes
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psnet.ahrq.gov/issue/human-error-medicine
July 06, 2011 - This book, published well in advance of the Institute of Medicine report To Err is Human , includes
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psnet.ahrq.gov/issue/promethazine-hcl-marketed-phenergan-information
May 04, 2015 - This alert highlights the dangers of administering promethazine hydrochloride to young children and includes
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psnet.ahrq.gov/issue/rx-errors-speed-high-volume-can-trigger-mistakes
September 24, 2017 - uncovers the factors involved in pharmacy errors, relates stories of patients harmed by such errors, and includes
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psnet.ahrq.gov/issue/unintended-consequences-new-problems-and-new-solutions
June 27, 2018 - This special issue includes studies, commentaries, and reviews exploring consequences of health IT, including
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psnet.ahrq.gov/node/867133/psn-pdf
November 13, 2024 - The Safe
Medication in Nursing Home Residents (SAME) intervention includes materials to define key roles
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psnet.ahrq.gov/node/866435/psn-pdf
August 07, 2024 - This review
analyzed research on standardized handoffs in acute care surgery, which includes trauma,
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psnet.ahrq.gov/node/865709/psn-pdf
May 01, 2024 - This article includes a narrative review
and interviews with one American nurse and 15 Israeli pediatric
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psnet.ahrq.gov/node/867337/psn-pdf
December 11, 2024 - The Safety I framework includes using
individual and system failures, analytics, culture, and technology
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psnet.ahrq.gov/node/866398/psn-pdf
July 31, 2024 - The
Patient Advocacy Reporting System (PARS) includes a peer messenger component for the small
proportion
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psnet.ahrq.gov/node/867083/psn-pdf
November 06, 2024 - This
communication includes not only telling the patient what their diagnosis is but also ensuring they
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psnet.ahrq.gov/node/45125/psn-pdf
January 26, 2023 - This list includes medications recognized by clinicians and professional organizations as those
suited
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psnet.ahrq.gov/node/838917/psn-pdf
October 26, 2022 - The e-Autopsy/e-Biopsy method
includes dedicated patient safety staff and volunteer clinical specialists
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psnet.ahrq.gov/node/844555/psn-pdf
February 15, 2023 - This collection of AHRQ-funded work
includes summaries of 53 projects since 2000 that contributed to
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psnet.ahrq.gov/node/838024/psn-pdf
September 07, 2022 - This scoping review includes 34 studies from the United States and
international settings and identified
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psnet.ahrq.gov/node/838131/psn-pdf
January 01, 2023 - what-i-wish-id-known-how-experienced-physician-managers-diagnose-treat-
and-prevent-disruptive
Disruptive behavior includes
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psnet.ahrq.gov/node/840142/psn-pdf
November 16, 2022 - This review includes 12 studies where participants were observed opening a
variety of medication packages