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psnet.ahrq.gov/node/45452/psn-pdf
August 24, 2016 - What price must we pay for safety? Excessive cost of
EPINEPHrine auto-injectors leads to error-prone use of
ampuls or vials and unprepared consumers.
August 24, 2016
ISMP Medication Safety Alert! Acute Care Edition. August 11, 2016;21:1-3.
https://psnet.ahrq.gov/issue/what-price-must-we-pay-safety-excessive-cost-e…
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psnet.ahrq.gov/node/42918/psn-pdf
February 05, 2014 - Ascension Health's demonstration of full disclosure
protocol for unexpected events during labor and delivery
shows promise.
February 5, 2014
Hendrich A, McCoy CK, Gale J, et al. Ascension health's demonstration of full disclosure protocol for
unexpected events during labor and delivery shows promise. Health Aff (M…
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psnet.ahrq.gov/node/39322/psn-pdf
February 24, 2010 - Complications and death at the start of the new academic
year: is there a July phenomenon?
February 24, 2010
Inaba K, Recinos G, Teixeira PGR, et al. Complications and death at the start of the new academic year: is
there a July phenomenon? J Trauma. 2010;68(1):19-22. doi:10.1097/TA.0b013e3181b88dfe.
https://psnet…
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psnet.ahrq.gov/node/45521/psn-pdf
December 21, 2016 - The effectiveness and risks of long-term opioid therapy
for chronic pain: a systematic review for a National
Institutes of Health Pathways to Prevention Workshop.
December 21, 2016
Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic
pain: a systematic review for…
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psnet.ahrq.gov/node/866442/psn-pdf
August 07, 2024 - Frequency and characteristics of errors by artificial
intelligence (AI) in reading screening mammography: a
systematic review.
August 7, 2024
Zeng A, Houssami N, Noguchi N, et al. Frequency and characteristics of errors by artificial intelligence (AI)
in reading screening mammography: a systematic review. Breast C…
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psnet.ahrq.gov/node/72474/psn-pdf
January 01, 2021 - Associations of physicians’ prescribing experience, work
hours, and workload with prescription errors.
November 18, 2020
Leviatan I, Oberman B, Zimlichman E, et al. Associations of physicians’ prescribing experience, work
hours, and workload with prescription errors. J Am Med Inform Assoc. 2021;28(6):1074-1080.
do…
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psnet.ahrq.gov/node/838188/psn-pdf
September 28, 2022 - Changes in unprofessional behaviour, teamwork, and co-
operation among hospital staff during the COVID-19
pandemic.
September 28, 2022
Westbrook JI, McMullan R, Urwin R, et al. Changes in unprofessional behaviour, teamwork and co?
operation among hospital staff during the COVID?19 pandemic. Intern Med J. 2022;52(1…
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psnet.ahrq.gov/node/46255/psn-pdf
September 06, 2017 - Patient Safety in the Home: Assessment of Issues,
Challenges, and Opportunities.
September 6, 2017
Carpenter D, Famolaro T, Hassell S, et al. Cambridge, MA: Institute for Healthcare Improvement; 2017.
https://psnet.ahrq.gov/issue/patient-safety-home-assessment-issues-challenges-and-opportunities
The ambulatory env…
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psnet.ahrq.gov/node/46133/psn-pdf
May 24, 2017 - Implementing smart infusion pumps with dose-error
reduction software: real-world experiences.
May 24, 2017
Heron C. Implementing smart infusion pumps with dose-error reduction software: real-world experiences.
Br J Nurs. 2017;26(8):S13-S16. doi:10.12968/bjon.2017.26.8.S13.
https://psnet.ahrq.gov/issue/implementing…
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psnet.ahrq.gov/node/46084/psn-pdf
February 21, 2018 - The effect of facility characteristics on patient safety,
patient experience, and service availability for procedures
in non–hospital-affiliated outpatient settings: a systematic
review.
February 21, 2018
Berglas NF, Battistelli MF, Nicholson WK, et al. The effect of facility characteristics on patient safety,
pa…
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psnet.ahrq.gov/node/43710/psn-pdf
October 06, 2016 - Improving medication administration safety: using naïve
observation to assess practice and guide improvements
in process and outcomes.
October 6, 2016
Donaldson N, Aydin C, Fridman M, et al. Improving medication administration safety: using naïve
observation to assess practice and guide improvements in process and…
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psnet.ahrq.gov/node/73062/psn-pdf
January 01, 2022 - Description of the role of pharmacist independent double
checks during cognitive order verification of outpatient
parenteral anti-cancer therapy.
March 25, 2021
Booth JP, Kennerly-Shah JM, Hartman AD. Description of the role of pharmacist independent double
checks during cognitive order verification of outpatient …
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psnet.ahrq.gov/node/846760/psn-pdf
March 29, 2023 - Electronic health record-based prediction models for in-
hospital adverse drug event diagnosis or prognosis: a
systematic review.
March 29, 2023
Yasrebi-de Kom IAR, Dongelmans DA, de Keizer NF, et al. Electronic health record-based prediction
models for in-hospital adverse drug event diagnosis or prognosis: a syst…
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psnet.ahrq.gov/node/34694/psn-pdf
February 10, 2011 - Computerized surveillance of adverse drug events in
hospital patients.
February 10, 2011
Classen DC, Pestotnik SL, Evans RS, et al. Computerized surveillance of adverse drug events in hospital
patients. JAMA. 1991;266(20):2847-51.
https://psnet.ahrq.gov/issue/computerized-surveillance-adverse-drug-events-hospital-…
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psnet.ahrq.gov/node/867047/psn-pdf
October 30, 2024 - Therapeutic errors involving diabetes medications
reported to United States poison centers.
October 30, 2024
Thurgood Giarman A, Hays HL, Badeti J, et al. Therapeutic errors involving diabetes medications reported
to United States poison centers. Inj Epidemiol. 2024;11(1):51. doi:10.1186/s40621-024-00536-y.
https:…
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psnet.ahrq.gov/node/867388/psn-pdf
December 18, 2024 - Secure messaging use and wrong-patient ordering errors
among inpatient clinicians.
December 18, 2024
Lou SS, Lew D, Xia L, et al. Secure messaging use and wrong-patient ordering errors among inpatient
clinicians. JAMA Netw Open. 2024;7(12):e2447797. doi:10.1001/jamanetworkopen.2024.47797.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/859343/psn-pdf
December 20, 2023 - Reducing retained foreign objects in the operating room:
a quality improvement initiative.
December 20, 2023
Keane OA, Chambers C, Brady CM, et al. Reducing retained foreign objects in the operating room: a
quality improvement initiative. J Am Coll Surg. 2023;237(6):864-872. doi:10.1097/xcs.0000000000000847.
https…
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psnet.ahrq.gov/node/48040/psn-pdf
July 24, 2019 - Potentially inappropriate prescribing among older
persons: a meta-analysis of observational studies.
July 24, 2019
Liew TM, Lee CS, Shawn KLG, et al. Potentially Inappropriate Prescribing Among Older Persons: A Meta-
Analysis of Observational Studies. Ann Fam Med. 2019;17(3):257-266. doi:10.1370/afm.2373.
https://…
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psnet.ahrq.gov/node/850165/psn-pdf
June 07, 2023 - Adolescents identifying errors and omissions in their
electronic health records: a national survey.
June 7, 2023
Hagström J, Blease CR, Kharko A, et al. Adolescents identifying errors and omissions in their electronic
health records: a national survey. Stud Health Technol Inform. 2023;302:242-246. doi:10.3233/shti2…
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psnet.ahrq.gov/node/843324/psn-pdf
February 01, 2023 - Cost of inpatient falls and cost-benefit analysis of
implementation of an evidence-based fall prevention
program.
February 1, 2023
Dykes PC, Curtin-Bowen M, Lipsitz S, et al. Cost of inpatient falls and cost-benefit analysis of
implementation of an evidence-based fall prevention program. JAMA Health Forum. 2023;4(…