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psnet.ahrq.gov/node/60874/psn-pdf
September 02, 2020 - A national mixed-methods evaluation of preparedness for
general surgery residency and the association with
resident burnout.
September 2, 2020
Engelhardt KE, Bilimoria KY, Johnson JK, et al. A national mixed-methods evaluation of preparedness for
general surgery residency and the association with resident burnout.…
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psnet.ahrq.gov/node/50414/psn-pdf
September 04, 2019 - Rating the raters: an evaluation of publicly reported
hospital quality rating systems.
September 4, 2019
Bilimoria KY, Birkmeyer JD, Burstin H, et al. NEJM Catalyst. August 14, 2019.
https://psnet.ahrq.gov/issue/rating-raters-evaluation-publicly-reported-hospital-quality-rating-systems
Numerous publicly available …
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psnet.ahrq.gov/node/38940/psn-pdf
November 25, 2009 - The role of advice in medication administration errors in
the pediatric ambulatory setting.
November 25, 2009
Lemer C, Bates DW, Yoon CS, et al. The role of advice in medication administration errors in the pediatric
ambulatory setting. J Patient Saf. 2009;5(3):168-75. doi:10.1097/PTS.0b013e3181b3a9b0.
https://psn…
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psnet.ahrq.gov/node/46107/psn-pdf
August 16, 2017 - The relationship between patient safety climate and
occupational safety climate in healthcare—a multi-level
investigation.
August 16, 2017
Pousette A, Larsman P, Eklöf M, et al. The relationship between patient safety climate and occupational
safety climate in healthcare – A multi-level investigation. J Safety Res…
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psnet.ahrq.gov/node/43311/psn-pdf
July 02, 2014 - Some IV medications are diluted unnecessarily in patient
care areas, creating undue risk.
July 2, 2014
ISMP Medication Safety Alert! Acute Care Edition. June 19, 2014;19:1-5.
https://psnet.ahrq.gov/issue/some-iv-medications-are-diluted-unnecessarily-patient-care-areas-creating-
undue-risk
This newsletter article …
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psnet.ahrq.gov/node/74842/psn-pdf
February 16, 2022 - An initiative to reduce insulin-related adverse drug events
in a children's hospital.
February 16, 2022
Lawson SA, Hornung LN, Lawrence M, et al. An initiative to reduce insulin-related adverse drug events in a
children's hospital. Pediatrics. 2022;149(1):e2020004937. doi:10.1542/peds.2020-004937.
https://psnet.ah…
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psnet.ahrq.gov/node/73419/psn-pdf
June 23, 2021 - Obtaining the best possible medication history at hospital
admission: description of a pharmacy technician-driven
program to identify medication discrepancies.
June 23, 2021
Kabir R, Liaw S, Cerise J, et al. Obtaining the best possible medication history at hospital admission:
description of a pharmacy technician-…
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psnet.ahrq.gov/node/43179/psn-pdf
July 28, 2014 - The effect of the electronic transmission of prescriptions
on dispensing errors and prescription enhancements
made in English community pharmacies: a naturalistic
stepped wedge study.
July 28, 2014
Franklin BD, Reynolds M, Sadler S, et al. The effect of the electronic transmission of prescriptions on
dispensing e…
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psnet.ahrq.gov/node/60940/psn-pdf
September 23, 2020 - Impact of interoperability of smart infusion pumps and an
electronic medical record in critical care.
September 23, 2020
Joseph R, Lee SW, Anderson SV, et al. Impact of interoperability of smart infusion pumps and an electronic
medical record in critical care. Am J Health-System Pharm. 2020;77(15):1231-1236.
doi:1…
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psnet.ahrq.gov/issue/factors-associated-hospital-admission-after-outpatient-surgery-veterans-health-administration
August 17, 2018 - detected by the Veterans Health Administration Surgical Quality Improvement Program and the Patient Safety Indicators … June 5, 2013
Validity of selected patient safety indicators: opportunities and concerns
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psnet.ahrq.gov/issue/opportunities-and-challenges-quality-and-safety-applications-icd-11-international-survey
February 17, 2017 - Related Resources From the Same Author(s)
Deriving ICD-10 codes for patient safety indicators … November 30, 2022
Application of patient safety indicators internationally: a pilot study
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psnet.ahrq.gov/node/850678/psn-pdf
June 14, 2023 - care and escalation plan.7
Context of the Innovation
Failure to identify, communicate, or act on indicators
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psnet.ahrq.gov/web-mm/forgotten-radiographic-read
June 07, 2016 - Do patient safety indicators explain increased weekend mortality? J Surg Res. 2016;200:164-170.
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psnet.ahrq.gov/node/50570/psn-pdf
October 23, 2019 - Does simulation training for acute care nurses improve
patient safety outcomes: a systematic review to inform
evidence-based practice.
October 23, 2019
Lewis KA, Ricks TN, Rowin A, et al. Does Simulation Training for Acute Care Nurses Improve Patient
Safety Outcomes: A Systematic Review to Inform Evidence-Based Pr…
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psnet.ahrq.gov/node/37054/psn-pdf
September 30, 2011 - Impact of the nurse shortage on hospital patient care:
comparative perspectives.
September 30, 2011
Buerhaus P, Donelan K, Ulrich BT, et al. Impact of the nurse shortage on hospital patient care: comparative
perspectives. Health Aff (Millwood). 2007;26(3):853-62.
https://psnet.ahrq.gov/issue/impact-nurse-shortage-…
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psnet.ahrq.gov/node/61069/psn-pdf
October 28, 2020 - Exploring psychological safety in healthcare teams to
inform the development of interventions: combining
observational, survey and interview data.
October 28, 2020
O’Donovan R, McAuliffe E. Exploring psychological safety in healthcare teams to inform the development
of interventions: combining observational, surve…
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psnet.ahrq.gov/node/845071/psn-pdf
February 22, 2023 - Speaking up as an extension of socio-cultural dynamics
in hospital settings: a study of staff experiences of
speaking up across seven hospitals.
February 22, 2023
Pavithra A, Mannion R, Sunderland N, et al. Speaking up as an extension of socio-cultural dynamics
in hospital settings: a study of staff experiences of…
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psnet.ahrq.gov/node/47846/psn-pdf
March 06, 2019 - Assessment of the FDA Risk Evaluation and Mitigation
Strategy for transmucosal immediate-release fentanyl
products.
March 6, 2019
Rollman JE, Heyward J, Olson L, et al. Assessment of the FDA Risk Evaluation and Mitigation Strategy for
Transmucosal Immediate-Release Fentanyl Products. JAMA. 2019;321(7):676-685.
do…
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psnet.ahrq.gov/node/837663/psn-pdf
July 13, 2022 - Long-term risk of overdose or mental health crisis after
opioid dose tapering.
July 13, 2022
Fenton JJ, Magnan E, Tseregounis IE, et al. Long-term risk of overdose or mental health crisis after opioid
dose tapering. JAMA Netw Open. 2022;5(6):e2216726. doi:10.1001/jamanetworkopen.2022.16726.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/60725/psn-pdf
July 29, 2020 - The tradeoffs between safety and alert fatigue: data from
a national evaluation of hospital medication-related
clinical decision support.
July 29, 2020
Co Z, Holmgren AJ, Classen DC, et al. The tradeoffs between safety and alert fatigue: data from a national
evaluation of hospital medication-related clinical decis…