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psnet.ahrq.gov/node/36479/psn-pdf
February 06, 2008 - Oral Dosage Forms that Should Not Be Crushed.
February 6, 2008
Mitchell JF; Institute for Safe Medications Practices; ISMP.
https://psnet.ahrq.gov/issue/oral-dosage-forms-should-not-be-crushed
To ensure that certain medications are used safely, this updated list includes oral medications that should
not be crushed…
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psnet.ahrq.gov/issue/descriptive-study-morbidity-and-mortality-conferences-and-their-conformity-medical-incident
September 28, 2010 - Study
A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: results of the morbidity and mortality conference improvement study, phase 1.
Citation Text:
Aboumatar HJ, Blackledge CG, Dickson C, et al. A descriptive study of …
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psnet.ahrq.gov/issue/effects-health-information-technology-patient-outcomes-systematic-review
December 03, 2018 - Review
Classic
Effects of health information technology on patient outcomes: a systematic review.
Citation Text:
Brenner SK, Kaushal R, Grinspan Z, et al. Effects of health information technology on patient outcomes: a systematic review. J Am Med Inform Assoc. 2…
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psnet.ahrq.gov/issue/long-road-patient-safety-status-report-patient-safety-systems
October 04, 2011 - Study
Classic
The long road to patient safety: a status report on patient safety systems.
Citation Text:
Longo DR, Hewett JE, Ge B, et al. The long road to patient safety: a status report on patient safety systems. JAMA. 2005;294(22):2858-65.
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…
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psnet.ahrq.gov/issue/establishing-international-baseline-medication-safety-oncology-findings-2012-ismp
May 14, 2009 - Study
Establishing an international baseline for medication safety in oncology: findings from the 2012 ISMP International Medication Safety Self Assessment for Oncology.
Citation Text:
Greenall J, Shastay A, Vaida AJ, et al. Establishing an international baseline for medication safety in…
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psnet.ahrq.gov/issue/measuring-hospital-adverse-events-assessing-inter-rater-reliability-and-trigger-performance
May 07, 2014 - Study
Measuring hospital adverse events: assessing inter-rater reliability and trigger performance of the Global Trigger Tool.
Citation Text:
Naessens JM, O'Byrne TJ, Johnson MG, et al. Measuring hospital adverse events: assessing inter-rater reliability and trigger performance of the …
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psnet.ahrq.gov/issue/developing-and-implementing-standardized-process-global-trigger-tool-application-across-large
July 18, 2017 - Study
Developing and implementing a standardized process for Global Trigger Tool application across a large health system.
Citation Text:
Garrett PR, Sammer C, Nelson A, et al. Developing and implementing a standardized process for global trigger tool application across a large health …
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psnet.ahrq.gov/issue/evaluation-culture-safety-survey-clinicians-and-managers-academic-medical-center
September 28, 2010 - Study
Classic
Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center.
Citation Text:
Pronovost PJ, Weast B, Holzmueller CG, et al. Evaluation of the culture of safety: survey of clinicians and managers in an academ…
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psnet.ahrq.gov/issue/improving-health-care-quality-and-patient-safety-through-peer-peer-assessment-demonstration
March 14, 2018 - Study
Improving health care quality and patient safety through peer-to-peer assessment: demonstration project in two academic medical centers.
Citation Text:
Mort E, Bruckel J, Donelan K, et al. Improving Health Care Quality and Patient Safety Through Peer-to-Peer Assessment: Demonstrati…
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psnet.ahrq.gov/issue/hospital-characteristics-associated-penalties-centers-medicare-medicaid-services-hospital
November 18, 2016 - Study
Hospital characteristics associated with penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program.
Citation Text:
Rajaram R, Chung JW, Kinnier C, et al. Hospital Characteristics Associated With Penalties in the Centers for Medicare & M…
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psnet.ahrq.gov/issue/electronic-trigger-based-care-escalation-identify-preventable-adverse-events-hospitalised
September 28, 2016 - Study
Classic
An electronic trigger based on care escalation to identify preventable adverse events in hospitalised patients.
Citation Text:
Bhise V, Sittig DF, Vaghani V, et al. An electronic trigger based on care escalation to identify preventable adverse even…
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psnet.ahrq.gov/issue/barriers-emergency-departments-adherence-four-medication-safety-related-joint-commission
October 19, 2022 - Study
Barriers to emergency departments' adherence to four medication safety–related Joint Commission National Patient Safety Goals.
Citation Text:
Juarez A, Gacki-Smith J, Bauer MR, et al. Barriers to emergency departments' adherence to four medication safety-related Joint Commission …
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psnet.ahrq.gov/issue/demonstrating-high-reliability-accountability-measures-johns-hopkins-hospital
January 27, 2016 - Study
Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital.
Citation Text:
Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531…
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psnet.ahrq.gov/issue/effects-hospital-safety-scores-total-price-out-pocket-cost-and-household-income-consumers
July 02, 2014 - Study
The effects of hospital safety scores, total price, out-of-pocket cost, and household income on consumers' self-reported choice of hospitals.
Citation Text:
Duke CC, Smith B, Lynch W, et al. The Effects of Hospital Safety Scores, Total Price, Out-of-Pocket Cost, and Household Incom…
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psnet.ahrq.gov/issue/speaking-about-safety-concerns-multi-setting-qualitative-study-patients-views-and-experiences
May 18, 2016 - Study
Speaking up about safety concerns: multi-setting qualitative study of patients' views and experiences.
Citation Text:
Entwistle VA, McCaughan D, Watt I, et al. Speaking up about safety concerns: multi-setting qualitative study of patients' views and experiences. Qual Saf Health C…
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psnet.ahrq.gov/issue/transparent-and-open-discussion-errors-does-not-increase-malpractice-risk-trauma-patients
October 19, 2022 - Study
Transparent and open discussion of errors does not increase malpractice risk in trauma patients.
Citation Text:
Stewart RM, Corneille MG, Johnston J, et al. Transparent and open discussion of errors does not increase malpractice risk in trauma patients. Ann Surg. 2006;243(5):645-9;…
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psnet.ahrq.gov/node/60864/psn-pdf
August 31, 2020 - Safety Across The Board
August 31, 2020
Fitall E, Hall KK, Gale B. Safety Across The Board . PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/safety-across-board
Defining Safety Across the Board
Safety Across The Board (SAB) is a concept originating from the Centers for Medicare & Medicaid Services
(CMS…
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psnet.ahrq.gov/issue/results-effort-integrate-quality-and-safety-medical-and-nursing-school-curricula-and-foster
September 08, 2021 - Study
Results of an effort to integrate quality and safety into medical and nursing school curricula and foster joint learning.
Citation Text:
Headrick LA, Barton AJ, Ogrinc G, et al. Results of an effort to integrate quality and safety into medical and nursing school curricula and fos…
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psnet.ahrq.gov/issue/developing-and-evaluating-automated-all-cause-harm-trigger-system
July 31, 2013 - Study
Developing and evaluating an automated all-cause harm trigger system.
Citation Text:
Sammer C, Miller S, Jones C, et al. Developing and Evaluating an Automated All-Cause Harm Trigger System. Jt Comm J Qual Patient Saf. 2017;43(4):155-165. doi:10.1016/j.jcjq.2017.01.004.
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psnet.ahrq.gov/issue/interpretive-diagnostic-error-reduction-surgical-pathology-and-cytology-guideline-college
February 10, 2012 - Organizational Policy/Guidelines
Interpretive diagnostic error reduction in surgical pathology and cytology: guideline from the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology.
Citation Text:
Nak…