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psnet.ahrq.gov/node/41132/psn-pdf
March 13, 2012 - Spreading a medication administration intervention
organizationwide in six hospitals.
March 13, 2012
Kliger J, Singer SJ, Hoffman F, et al. Spreading a medication administration intervention organizationwide
in six hospitals. Jt Comm J Qual Patient Saf. 2012;38(2):51-60.
https://psnet.ahrq.gov/issue/spreading-medi…
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psnet.ahrq.gov/node/41814/psn-pdf
March 04, 2015 - Autopsy as a quality control measure for radiology, and
vice versa.
March 4, 2015
Murken DR, Ding M, Branstetter BF, et al. Autopsy as a quality control measure for radiology, and vice
versa. AJR Am J Roentgenol. 2012;199(2):394-401. doi:10.2214/AJR.11.8386.
https://psnet.ahrq.gov/issue/autopsy-quality-control-mea…
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psnet.ahrq.gov/node/44930/psn-pdf
June 01, 2016 - How well is quality improvement described in the
perioperative care literature? A systematic review.
June 1, 2016
Jones EL, Lees N, Martin G, et al. How Well Is Quality Improvement Described in the Perioperative Care
Literature? A Systematic Review. Jt Comm J Qual Patient Saf. 2016;42(5):196-206.
https://psnet.ahr…
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psnet.ahrq.gov/node/35451/psn-pdf
January 05, 2017 - Closing the loop: follow-up and feedback in a patient
safety program.
January 5, 2017
Gandhi TK, Graydon-Baker E, Huber CN, et al. Closing the loop: follow-up and feedback in a patient safety
program. Jt Comm J Qual Patient Saf. 2005;31(11):614-21.
https://psnet.ahrq.gov/issue/closing-loop-follow-and-feedback-pati…
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psnet.ahrq.gov/node/37487/psn-pdf
May 26, 2011 - Predicting computerized physician order entry system
adoption in US hospitals: can the federal mandate be
met?
May 26, 2011
Ford EW, McAlearney AS, Phillips MT, et al. Predicting computerized physician order entry system
adoption in US hospitals: Can the federal mandate be met? Int J Med Inform. 2007;77(8).
doi:1…
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psnet.ahrq.gov/node/45014/psn-pdf
July 18, 2016 - Improving patient safety through simulation training in
anesthesiology: where are we?
July 18, 2016
Green M, Tariq R, Green P. Improving Patient Safety through Simulation Training in Anesthesiology:
Where Are We? Anesthesiol Res Pract. 2016;2016:4237523. doi:10.1155/2016/4237523.
https://psnet.ahrq.gov/issue/impro…
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psnet.ahrq.gov/node/74705/psn-pdf
January 26, 2022 - 20 years after To Err Is Human: a bibliometric analysis of
‘the IOM report’s’ impact on research on patient safety.
January 26, 2022
St.Pierre M, Grawe P, Bergström J, et al. 20 years after To Err Is Human: a bibliometric analysis of ‘the
IOM report’s’ impact on research on patient safety. Safety Sci. 2021;147:1055…
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psnet.ahrq.gov/node/836821/psn-pdf
March 30, 2022 - Biasing influence of 'mental shortcuts' on diagnostic
decision-making: radiologists can overlook breast cancer
in mamograms when prior diagnostic information is
available.
March 30, 2022
Branch F, Santana I, Hegdé J. Biasing influence of 'mental shortcuts' on diagnostic decision-making:
radiologists can overlook …
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psnet.ahrq.gov/node/36834/psn-pdf
August 26, 2011 - Healthcare climate: a framework for measuring and
improving patient safety.
August 26, 2011
Zohar D, Livne Y, Tenne-Gazit O, et al. Healthcare climate: a framework for measuring and improving
patient safety. Crit Care Med. 2007;35(5):1312-7.
https://psnet.ahrq.gov/issue/healthcare-climate-framework-measuring-and-i…
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psnet.ahrq.gov/node/865723/psn-pdf
June 18, 2024 - Using AHRQ’s SOPS Hospital Survey and Workplace
Safety Item Set: Experiences From a State Hospital
Association.
June 18, 2024
Agency for Healthcare Research and Quality. May 23, 2024.
https://psnet.ahrq.gov/issue/using-ahrqs-sops-hospital-survey-and-workplace-safety-item-set-experiences-
state-hospital
An unders…
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psnet.ahrq.gov/node/848813/psn-pdf
May 10, 2023 - Blood and blood products transfusion errors: what can
we do to improve patient safety.
May 10, 2023
Brown C, Brown M. Blood and blood products transfusion errors: what can we do to improve patient
safety? Br J Nurs. 2023;32(7):326-332. doi:10.12968/bjon.2023.32.7.326.
https://psnet.ahrq.gov/issue/blood-and-blood-p…
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psnet.ahrq.gov/node/73655/psn-pdf
September 01, 2021 - Influence of organizational climate and clinician morale
on seclusion and physical restraint use in inpatient
psychiatric units.
September 1, 2021
Anderson E, Mohr DC, Regenbogen I, et al. Influence of organizational climate and clinician morale on
seclusion and physical restraint use in inpatient psychiatric unit…
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psnet.ahrq.gov/node/44948/psn-pdf
February 14, 2017 - Safer Healthcare: Strategies for the Real World.
February 14, 2017
Vincent C, Amalberti R. New York, NY: SpringerOpen; 2016
https://psnet.ahrq.gov/issue/safer-healthcare-strategies-real-world
Written by two leaders in the patient safety field, Charles Vincent and Rene Amalberti, this book is available
for free dow…
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psnet.ahrq.gov/node/36280/psn-pdf
May 27, 2011 - Types of unintended consequences related to
computerized provider order entry.
May 27, 2011
Campbell EM, Sittig DF, Ash JS, et al. Types of unintended consequences related to computerized
provider order entry. J Am Med Inform Assoc. 2006;13(5):547-56.
https://psnet.ahrq.gov/issue/types-unintended-consequences-rela…
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psnet.ahrq.gov/node/836998/psn-pdf
April 27, 2022 - How will state medical boards handle cases involving
disclosure and apology for medical errors?
April 27, 2022
Wojcieszak D. How will state medical boards handle cases involving disclosure and apology for medical
errors? J Patient Saf Risk Manag. 2022;27(1):15-20. doi:10.1177/25160435211070096.
https://psnet.ahrq.…
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psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
January 13, 2021 - Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative
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psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
January 01, 2014 - Antimicrobial resistance prevention initiative--an update: proceedings of an expert panel on resistance
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psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
March 27, 2024 - SPOTLIGHT CASE
Hidden Heparins: HIT Happens
Citation Text:
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - February 1, 2023
An initiative to reduce insulin-related adverse drug events in
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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - Clinics credits Children’s Hospital Colorado’s success as the motivation for implementing a similar initiative