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psnet.ahrq.gov/node/60994/psn-pdf
October 07, 2020 - Potentially inappropriate medication combination with
opioids among older dental patients: a retrospective
review of insurance claims data.
October 7, 2020
Zhou J, Calip GS, Rowan S, et al. Potentially inappropriate medication combination with opioids among
older dental patients: a retrospective review of insuranc…
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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/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/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/73591/psn-pdf
August 11, 2021 - Unintended consequences: quantifying the benefits,
iatrogenic harms and downstream cascade costs of
musculoskeletal MRI in UK primary care.
August 11, 2021
Sajid IM, Parkunan A, Frost K. Unintended consequences: quantifying the benefits, iatrogenic harms and
downstream cascade costs of musculoskeletal MRI in UK pr…
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psnet.ahrq.gov/node/45622/psn-pdf
December 07, 2016 - National Partnership for Maternal Safety: Consensus
Bundle on Venous Thromboembolism.
December 7, 2016
D'Alton ME, Friedman AM, Smiley RM, et al. National Partnership for Maternal Safety: Consensus Bundle
on Venous Thromboembolism. J Obstet Gynecol Neonatal Nurs. 2016;45(5):706-717.
doi:10.1016/j.jogn.2016.07.001.…
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psnet.ahrq.gov/node/837668/psn-pdf
July 13, 2022 - Factors associated with malpractice claim payout: an
analysis of closed emergency department claims.
July 13, 2022
Gupta K, Szymonifka J, Rivadeneira NA, et al. Factors associated with malpractice claim payout: an
analysis of closed emergency department claims. Jt Comm J Qual Patient Saf. 2022;48(9):492-496.
doi:1…
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psnet.ahrq.gov/node/48105/psn-pdf
July 10, 2019 - Teaching medical students to recognise and report
errors.
July 10, 2019
Mohsin SU, Ibrahim Y, Levine D. Teaching medical students to recognise and report errors. BMJ Open
Qual. 2019;8(2):e000558. doi:10.1136/bmjoq-2018-000558.
https://psnet.ahrq.gov/issue/teaching-medical-students-recognise-and-report-errors
This…
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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/837314/psn-pdf
June 01, 2022 - CMS proposal to suppress hospital safety data angers
advocates — agency says COVID disruptions, staff
shortages hamper ability to fairly score poor performers.
June 1, 2022
Clark C. MedPage Today. May 20, 2022.
https://psnet.ahrq.gov/issue/cms-proposal-suppress-hospital-safety-data-angers-advocates-agency-says-
c…
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psnet.ahrq.gov/node/851056/psn-pdf
June 28, 2023 - Introducing second-year medical students to diagnostic
reasoning concepts and skills via a virtual curriculum.
June 28, 2023
Chang C, Varghese N, Machiorlatti M. Introducing second-year medical students to diagnostic reasoning
concepts and skills via a virtual curriculum. Diagnosis (Berl). 2023;10(2):105-109. doi:1…
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psnet.ahrq.gov/node/73566/psn-pdf
August 04, 2021 - Personal formularies of primary care physicians across 4
health care systems.
August 4, 2021
Galanter W, Eguale T, Gellad WF, et al. Personal formularies of primary care physicians across 4 health
care systems. JAMA Netw Open. 2021;4(7):e2117038. doi:10.1001/jamanetworkopen.2021.17038.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/72647/psn-pdf
January 20, 2021 - Association of unexpected newborn deaths with changes
in obstetric and neonatal process of care.
January 20, 2021
Han D, Khadka A, McConnell M, et al. Association of Unexpected Newborn Deaths With Changes in
Obstetric and Neonatal Process of Care. JAMA Netw Open. 2020;3(12):e2024589.
doi:10.1001/jamanetworkopen.20…
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psnet.ahrq.gov/node/844988/psn-pdf
February 22, 2023 - Assessment of patient retention of inpatient care
information post-hospitalization.
February 22, 2023
Townshend R, Grondin C, Gupta A, et al. Assessment of patient retention of inpatient care information
post-hospitalization. Jt Comm J Qual Patient Saf. 2023;49(2):70-78. doi:10.1016/j.jcjq.2022.11.002.
https://psn…
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psnet.ahrq.gov/node/43823/psn-pdf
June 07, 2017 - Safety perceptions of health care leaders in 2 Canadian
academic acute care centers.
June 7, 2017
Goldstein DH, Nyce JM, Van Den Kerkhof EG. Safety Perceptions of Health Care Leaders in 2 Canadian
Academic Acute Care Centers. J Patient Saf. 2017;13(2):62-68. doi:10.1097/PTS.0000000000000112.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/836962/psn-pdf
April 20, 2022 - Using human factors and ergonomics principles to
prevent inpatient falls.
April 20, 2022
Kwok Y-ting, Lam M-sang. Using human factors and ergonomics principles to prevent inpatient falls. BMJ
Open Qual. 2022;11(1):e001696. doi:10.1136/bmjoq-2021-001696.
https://psnet.ahrq.gov/issue/using-human-factors-and-ergonomi…
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psnet.ahrq.gov/node/37011/psn-pdf
September 24, 2010 - What do medical records tell us about potentially harmful
co-prescribing?
September 24, 2010
Lafata JE, Simpkins J, Kaatz S, et al. What do medical records tell us about potentially harmful co-
prescribing? Jt Comm J Qual Patient Saf. 2007;33(7):395-400.
https://psnet.ahrq.gov/issue/what-do-medical-records-tell-us…
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www.ahrq.gov/hai/cusp/toolkit/bckgrnd-qi-team.html
December 01, 2012 - Background Quality Improvement Team Information Form
CUSP Toolkit
Health care provider roles
Who should use this tool? Health care providers.
Please indicate people designated as Quality Improvement Team Members. Your team may not have people who serve in all of these roles.
These in…
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psnet.ahrq.gov/node/50733/psn-pdf
December 11, 2019 - Association between measured teamwork and medical
errors: an observational study of prehospital care in the
USA
December 11, 2019
Herzberg S, Hansen M, Schoonover A, et al. Association between measured teamwork and medical errors:
an observational study of prehospital care in the USA. BMJ Open. 2019;9(10):e025314.…