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4881. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73174/psn-pdf
      April 21, 2021 - Take Charge: 5 Steps to Safer Healthcare. April 21, 2021 Wantagh, NY; Pulse Center for Patient Safety, Education & Advocacy. https://psnet.ahrq.gov/issue/take-charge-5-steps-safer-healthcare Patients can be active partners in their own safe care. This five-step program provides information and education for pa…

4882. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38304/psn-pdf
      December 17, 2008 - ISMP Announces 11th Annual Cheers Awards Recipients. December 17, 2008 https://psnet.ahrq.gov/issue/ismp-announces-11th-annual-cheers-awards-recipients The Cheers awards annually recognize leaders in the field of medication safety. Among the 2008 honorees are FDA Patient Safety News; the Health Information Translat…

4883. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35444/psn-pdf
      March 11, 2011 - Improving acceptance of computerized prescribing alerts in ambulatory care. March 11, 2011 Shah N, Seger AC, Seger DL, et al. Improving acceptance of computerized prescribing alerts in ambulatory care. J Am Med Inform Assoc. 2006;13(1):5-11. https://psnet.ahrq.gov/issue/improving-acceptance-computerized-prescribin…

4884. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41671/psn-pdf
      September 12, 2012 - Quality indicators to detect pre-analytical errors in laboratory testing. September 12, 2012 Plebani M. Quality indicators to detect pre-analytical errors in laboratory testing. Clin Biochem Rev. 2012;33(3):85-8. https://psnet.ahrq.gov/issue/quality-indicators-detect-pre-analytical-errors-laboratory-testing This …

4885. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37010/psn-pdf
      March 10, 2011 - Randomized trial to improve prescribing safety during pregnancy. March 10, 2011 Raebel MA, Carroll NM, Kelleher JA, et al. Randomized trial to improve prescribing safety during pregnancy. J Am Med Inform Assoc. 2007;14(4):440-450. https://psnet.ahrq.gov/issue/randomized-trial-improve-prescribing-safety-during-preg…

4886. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40822/psn-pdf
      October 05, 2011 - Data consistency in a voluntary medical incident reporting system. October 5, 2011 Gong Y. Data consistency in a voluntary medical incident reporting system. J Med Syst. 2011;35(4):609-15. doi:10.1007/s10916-009-9398-y. https://psnet.ahrq.gov/issue/data-consistency-voluntary-medical-incident-reporting-system This…

4887. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35003/psn-pdf
      March 11, 2011 - Implementing a commercial rule base as a medication order safety net. March 11, 2011 Reichley RM, Seaton TL, Resetar E, et al. Implementing a commercial rule base as a medication order safety net. J Am Med Inform Assoc. 2005;12(4):383-9. https://psnet.ahrq.gov/issue/implementing-commercial-rule-base-medication-ord…

4888. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40720/psn-pdf
      August 24, 2011 - Incomplete care—on the trail of flaws in the system. August 24, 2011 Gandhi TK, Zuccotti G, Lee TH. Incomplete care--on the trail of flaws in the system. N Engl J Med. 2011;365(6):486-8. doi:10.1056/NEJMp1106313. https://psnet.ahrq.gov/issue/incomplete-care-trail-flaws-system This article describes how missing pat…

4889. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35202/psn-pdf
      December 23, 2016 - Preventing vincristine administration errors. December 23, 2016 Preventing vincristine administration errors. Sentinel Event Alert. 2005;34(34):1-3. https://psnet.ahrq.gov/issue/preventing-vincristine-administration-errors The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued this alert t…

4890. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35686/psn-pdf
      December 23, 2016 - Using medication reconciliation to prevent errors. December 23, 2016 Using medication reconciliation to prevent errors. Sentinel Event Alert. 2006;35(35):1-4. https://psnet.ahrq.gov/issue/using-medication-reconciliation-prevent-errors This alert emphasizes the importance of reconciling medications and supports impl…

4891. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36187/psn-pdf
      September 30, 2010 - Orienting frames and private routines: the role of cultural process in critical care safety. September 30, 2010 Hazlehurst B, McMullen C. Orienting frames and private routines: the role of cultural process in critical care safety. Int J Med Inform. 2007;76 Suppl 1:S129-35. https://psnet.ahrq.gov/issue/orienting-fr…

4892. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38450/psn-pdf
      March 04, 2009 - Variability in pharmacy interpretations of physician prescriptions. March 4, 2009 Wolf MS, Shekelle PG, Choudhry NK, et al. Variability in pharmacy interpretations of physician prescriptions. Med Care. 2009;47(3):370-373. doi:10.1097/MLR.0b013e31818af91a. https://psnet.ahrq.gov/issue/variability-pharmacy-interpret…

4893. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34621/psn-pdf
      September 27, 2017 - Human Factors and Medical Devices. September 27, 2017 Center for Devices and Radiological Health, US Food and Drug Administration. https://psnet.ahrq.gov/issue/human-factors-and-medical-devices Human factors engineering (HFE) helps improve human performance and reduce the risks associated with use error. The U.S. …

4894. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36146/psn-pdf
      February 05, 2019 - Guidelines for Design and Construction. February 5, 2019 St Louis, Missouri; Facilities Guidelines Institute; 2018. https://psnet.ahrq.gov/issue/guidelines-design-and-construction These updated guidelines include design changes, such as the adoption of private rooms to reduce medical error, interruptions, and hosp…

4895. National Action Alliance: Webinars | PSNet
      psnet.ahrq.gov/training-catalog/national-action-alliance-webinars
      August 10, 2025 - National Action Alliance: Webinars Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization Agency for Healthcare Research and Quality (AHRQ) Event Des…

4896. NIOSH Training for Nurses on Shift Work and Long Work Hours | PSNet
      psnet.ahrq.gov/training-catalog/niosh-training-nurses-shift-work-and-long-work-hours
      September 15, 2025 - NIOSH Training for Nurses on Shift Work and Long Work Hours Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization National Institute for Occupational Safety and Health (…

4897. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50850/psn-pdf
      January 29, 2020 - Better Safer Care Victoria. January 29, 2020 Safer Care Victoria and Victorian Agency for Health Information. https://psnet.ahrq.gov/issue/better-safer-care-victoria Large scale tracking of adverse care incidents offers evidence that governments and organizations can use to target care process improvement efforts.…

4898. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867769/psn-pdf
      March 12, 2025 - Lessons from Event Reports. March 12, 2025 Lessons from Event Reports. Patient Safety Authority. https://psnet.ahrq.gov/issue/lessons-event-reports Small successes can inform and motivate actions leading to sustainable, evidence-based change. This searchable collection of projects initiated in response to event re…

4899. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42061/psn-pdf
      October 05, 2015 - Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. October 5, 2015 Ganz DA, Huang C, Saliba D, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2013. AHRQ Publication No. 13-0015-EF. https://psnet.ahrq.gov/issue/preventing-falls-hospitals-toolkit-improving-quality-care…

4900. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38864/psn-pdf
      July 08, 2013 - Addressing the quality and safety gap—parts I-III. July 8, 2013 Princeton, NJ: Robert Wood Johnson Foundation; November 2010. https://psnet.ahrq.gov/issue/addressing-quality-and-safety-gap-parts-i-iii Part I of this three-part series examines the quality improvement experience of four health care organizations and…