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psnet.ahrq.gov/node/38068/psn-pdf
March 10, 2011 - The effect of electronic prescribing on medication errors
and adverse drug events: a systematic review.
March 10, 2011
Ammenwerth E, Schnell-Inderst P, Machan C, et al. The effect of electronic prescribing on medication
errors and adverse drug events: a systematic review. J Am Med Inform Assoc. 2008;15(5):585-600.
…
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psnet.ahrq.gov/node/44729/psn-pdf
January 07, 2016 - The morbidity and mortality meeting: time for a different
approach?
January 7, 2016
Fraser J. The morbidity and mortality meeting: time for a different approach? Arch Dis Child. 2016;101(1):4-
8. doi:10.1136/archdischild-2015-309536.
https://psnet.ahrq.gov/issue/morbidity-and-mortality-meeting-time-different-appro…
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psnet.ahrq.gov/node/42680/psn-pdf
October 30, 2013 - Developing a framework for nursing handover in the
emergency department: an individualised and systematic
approach.
October 30, 2013
Klim S, Kelly A-M, Kerr D, et al. Developing a framework for nursing handover in the emergency
department: an individualised and systematic approach. J Clin Nurs. 2013;22(15-16):2233…
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psnet.ahrq.gov/node/43219/psn-pdf
January 01, 2015 - Developing a reporting and tracking tool for nursing
student errors and near misses.
May 28, 2014
Disch J, Barnsteiner J. Developing a Reporting and Tracking Tool for Nursing Student Errors and Near
Misses. J Nurs Reg. 2015;5(1):4-10. doi:10.1016/s2155-8256(15)30093-4.
https://psnet.ahrq.gov/issue/developing-repor…
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psnet.ahrq.gov/node/38938/psn-pdf
July 26, 2023 - ISMP's List of Confused Drug Names.
July 26, 2023
Horsham, PA; Institute for Safe Medication Practices: July 2023.
https://psnet.ahrq.gov/issue/ismps-list-confused-drug-names
Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet
provides a comprehensive list of commonly…
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psnet.ahrq.gov/node/46161/psn-pdf
May 31, 2017 - Developing team cognition: a role for simulation.
May 31, 2017
Fernandez R, Shah S, Rosenman ED, et al. Developing Team Cognition. Simul Healthc. 2017;12(2):96-
103. doi:10.1097/sih.0000000000000200.
https://psnet.ahrq.gov/issue/developing-team-cognition-role-simulation
Simulation training has been advocated as a …
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psnet.ahrq.gov/node/44946/psn-pdf
February 01, 2017 - Quality gaps identified through mortality review.
February 1, 2017
Kobewka DM, van Walraven C, Turnbull J, et al. Quality gaps identified through mortality review. BMJ Qual
Saf. 2017;26(2):141-149. doi:10.1136/bmjqs-2015-004735.
https://psnet.ahrq.gov/issue/quality-gaps-identified-through-mortality-review
Inpatien…
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psnet.ahrq.gov/node/41440/psn-pdf
August 17, 2016 - The Toolkit for Using the AHRQ Quality Indicators: How
To Improve Hospital Quality and Safety.
August 17, 2016
Rockville, MD: Agency for Healthcare Research and Quality; July 2016.
https://psnet.ahrq.gov/issue/toolkit-using-ahrq-quality-indicators-how-improve-hospital-quality-and-safety
This toolkit provides resou…
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psnet.ahrq.gov/node/47260/psn-pdf
August 08, 2018 - Building the Case for Health Literacy: Proceedings of a
Workshop.
August 8, 2018
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press;
2018. ISBN: 9780309474290.
https://psnet.ahrq.gov/issue/building-case-health-literacy-proceedings-workshop
Health literacy affects p…
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psnet.ahrq.gov/node/74093/psn-pdf
November 17, 2021 - Prevent errors during emergency use of hypertonic
sodium chloride solutions.
November 17, 2021
ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4.
https://psnet.ahrq.gov/issue/prevent-errors-during-emergency-use-hypertonic-sodium-chloride-solutions
Delays in diagnosis and treatment duri…
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psnet.ahrq.gov/node/47220/psn-pdf
September 12, 2018 - Strategically Advancing Patient and Family Advisory
Councils in New York State Hospitals.
September 12, 2018
Bethesda, MD: Institute for Patient- and Family-Centered Care; June 2018.
https://psnet.ahrq.gov/issue/strategically-advancing-patient-and-family-advisory-councils-new-york-state-
hospitals
Hospital patien…
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psnet.ahrq.gov/node/34759/psn-pdf
July 13, 2016 - Human Error.
July 13, 2016
Reason JT. Cambridge, UK: Cambridge University Press; 1990. ISBN: 9780521306690.
https://psnet.ahrq.gov/issue/human-error
Despite writing almost nothing specifically on health care, clinical psychologist James Reason has
influenced modern thinking about medical errors more than any other…
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psnet.ahrq.gov/node/42873/psn-pdf
November 23, 2016 - Promoting engagement by patients and families to reduce
adverse events in acute care settings: a systematic
review.
November 23, 2016
Berger ZD, Flickinger TE, Pfoh ER, et al. Promoting engagement by patients and families to reduce
adverse events in acute care settings: a systematic review. BMJ Qual Saf. 2014;23(7…
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psnet.ahrq.gov/node/38970/psn-pdf
July 05, 2013 - Joint Commission Center for Transforming Healthcare.
July 5, 2013
Joint Commission.
https://psnet.ahrq.gov/issue/joint-commission-center-transforming-healthcare
The Joint Commission has traditionally focused on accreditation of health care organizations and, through
its Joint Commission Resources arm, on quality i…
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psnet.ahrq.gov/node/42544/psn-pdf
December 18, 2013 - Communicating medication changes to community
pharmacy post-discharge: the good, the bad, and the
improvements.
December 18, 2013
Urban R, Paloumpi E, Rana N, et al. Communicating medication changes to community pharmacy post-
discharge: the good, the bad, and the improvements. Int J Clin Pharm. 2013;35(5):813-20.…
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psnet.ahrq.gov/node/46512/psn-pdf
August 17, 2018 - The problem with using patient complaints for
improvement.
August 17, 2018
de Vos MS, Hamming JF, van de Mheen PJM-. The problem with using patient complaints for
improvement. BMJ Qual Saf. 2018;27(9):758-762. doi:10.1136/bmjqs-2017-007463.
https://psnet.ahrq.gov/issue/problem-using-patient-complaints-improvement
…
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psnet.ahrq.gov/node/867758/psn-pdf
March 12, 2025 - Errors in the EMR: under-recognized hazard for AI in
healthcare.
March 12, 2025
Morreim EH. Errors in the EMR: under-recognized hazard for AI in healthcare. Hous J Health Law Policy.
2025;24:127-165.
https://psnet.ahrq.gov/issue/errors-emr-under-recognized-hazard-ai-healthcare
Artificial intelligence (AI) systems…
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psnet.ahrq.gov/node/846458/psn-pdf
March 22, 2024 - National Healthcare Quality and Disparities Report
Chartbook on Patient Safety.
March 22, 2024
Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Pub. No. 23-0046.
https://psnet.ahrq.gov/issue/national-healthcare-quality-and-disparities-report-chartbook-patient-safety-0
The Network of Pati…
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psnet.ahrq.gov/perspective/safety-retail-pharmacy
May 11, 2016 - Safety in the Retail Pharmacy
Michelle A. Chui, PharmD, PhD | October 1, 2018
View more articles from the same authors.
Citation Text:
Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departme…
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psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - A Seasonal Care Transition Failure
July 1, 2011
Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
The Case
A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine
resident—for routine follow-up…