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psnet.ahrq.gov/node/865718/psn-pdf
May 01, 2024 - Calculating the cost of medication errors: a systematic
review of approaches and cost variables.
May 1, 2024
Ranasinghe S, Nadeshkumar A, Senadheera S, et al. Calculating the cost of medication errors: a
systematic review of approaches and cost variables. BMJ Open Qual. 2024;13(2):e002570.
doi:10.1136/bmjoq-2023-0…
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psnet.ahrq.gov/node/842424/psn-pdf
January 11, 2023 - Unsafe by design: infusion task reallocation and safety
perceptions in U.S. hospitals.
January 11, 2023
Pratt BR, Dunford BB, Vogus TJ, et al. Unsafe by design: infusion task reallocation and safety perceptions
in U.S. hospitals. Health Care Manage Rev. 2022;48(1):14-22. doi:10.1097/hmr.0000000000000351.
https://p…
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psnet.ahrq.gov/node/73703/psn-pdf
September 15, 2021 - To expand the evidence base about harms from tests and
treatments.
September 15, 2021
Korenstein D, Harris RP, Elshaug AG, et al. To expand the evidence base about harms from tests and
treatments. J Gen Intern Med. 2021;36(7):2105-2110. doi:10.1007/s11606-021-06597-9.
https://psnet.ahrq.gov/issue/expand-evidence-b…
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psnet.ahrq.gov/node/846756/psn-pdf
March 29, 2023 - Frequency of medication administration timing error in
hospitals: a systematic review.
March 29, 2023
Pullam T, Russell CL, White-Lewis S. Frequency of medication administration timing error in hospitals: a
systematic review. J Nurs Care Qual. 2023;38(2):126-133. doi:10.1097/ncq.0000000000000668.
https://psnet.ahr…
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psnet.ahrq.gov/node/73612/psn-pdf
August 18, 2021 - Evaluating the impact of radio frequency identification
retained surgical instruments tracking on patient safety:
literature review.
August 18, 2021
Schnock KO, Biggs B, Fladger A, et al. Evaluating the impact of radio frequency identification retained
surgical instruments tracking on patient safety: literature re…
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psnet.ahrq.gov/node/47825/psn-pdf
March 06, 2019 - Diagnostic error as a result of drug-laboratory test
interactions.
March 6, 2019
van Balveren JA, van de Venne WPHGV-, Erdem-Eraslan L, et al. Diagnostic error as a result of drug-
laboratory test interactions. Diagnosis (Berl). 2019;6(1):69-71. doi:10.1515/dx-2018-0098.
https://psnet.ahrq.gov/issue/diagnostic-err…
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psnet.ahrq.gov/node/837065/psn-pdf
May 11, 2022 - Fast tracking in cardiac surgery: is it safe?
May 11, 2022
MacLeod JB, D’Souza K, Aguiar C, et al. Fast tracking in cardiac surgery: is it safe? J Cardiothorac Surg.
2022;17(1):69. doi:10.1186/s13019-022-01815-9.
https://psnet.ahrq.gov/issue/fast-tracking-cardiac-surgery-it-safe
Post-operative complications can le…
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psnet.ahrq.gov/node/74089/psn-pdf
July 15, 2002 - The effect of race and sex on physicians'
recommendations for cardiac catheterization.
July 15, 2002
Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians' recommendations for
cardiac catheterization. N Engl J Med. 2002;340(8):618-626. doi:10.1056/nejm199902253400806.
https://psnet.ahr…
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psnet.ahrq.gov/node/61075/psn-pdf
October 28, 2020 - FDA advises health care professionals and patients about
insulin pen packaging and dispensing.
October 28, 2020
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 13, 2020.
https://psnet.ahrq.gov/issue/fda-advises-health-care-professionals-and-patients-about-insulin-pen-
packag…
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psnet.ahrq.gov/node/50402/psn-pdf
October 02, 2019 - Improving Diagnostic Fidelity: An Approach to
Standardizing the Process in Patients With Emerging
Critical Illness
October 2, 2019
Jayaprakash N, Chae J, Sabov M, et al. Improving Diagnostic Fidelity: An Approach to Standardizing the
Process in Patients With Emerging Critical Illness. Mayo Clin Proc Innov Qual Out…
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psnet.ahrq.gov/node/39446/psn-pdf
May 25, 2010 - Worries and concerns experienced by nurse specialists
during inter-hospital transports of critically ill patients: a
critical incident study.
May 25, 2010
Gustafsson M, Wennerholm S, Fridlund B. Worries and concerns experienced by nurse specialists during
inter-hospital transports of critically ill patients: a cri…
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psnet.ahrq.gov/node/46304/psn-pdf
November 01, 2017 - Comparative performance of pediatric weight estimation
techniques: a human factor errors analysis.
November 1, 2017
Abdel-Rahman SM, Jacobsen R, Watts JL, et al. Comparative performance of pediatric weight estimation
techniques: a human factor errors analysis. Pediatr Emerg Care. 2015;33(8):548-552.
doi:10.1097/pe…
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psnet.ahrq.gov/node/866824/psn-pdf
September 25, 2024 - 'Failing wisely' can promote a safer healthcare system.
September 25, 2024
Fleisher LA, Edmondson AC. 'Failing wisely' can promote a safer healthcare system. MedPage Today.
September 17, 2024;
https://psnet.ahrq.gov/issue/failing-wisely-can-promote-safer-healthcare-system
The ability to learn-by-doing in an enviro…
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psnet.ahrq.gov/node/838187/psn-pdf
September 28, 2022 - Diagnostic delays in infectious diseases.
September 28, 2022
Suneja M, Beekmann SE, Dhaliwal G, et al. Diagnostic delays in infectious diseases. Diagnosis (Berl).
2022;9(3):332-339. doi:10.1515/dx-2021-0092.
https://psnet.ahrq.gov/issue/diagnostic-delays-infectious-diseases
Delayed diagnosis of infectious diseases…
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psnet.ahrq.gov/node/33993/psn-pdf
March 02, 2011 - Improving patient care. My right knee.
March 2, 2011
Berwick DM. Improving patient care. My right knee. Ann Intern Med. 2005;142(2):121-5.
https://psnet.ahrq.gov/issue/improving-patient-care-my-right-knee
Dr. Donald Berwick writes this compelling piece as a personal reflection on the current deficiencies in
health…
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psnet.ahrq.gov/node/72481/psn-pdf
November 18, 2020 - Computer-based simulation to reduce EHR-related
chemotherapy ordering errors.
November 18, 2020
Wyatt KD, Freedman EB, Arteaga GM, et al. Computer?based simulation to reduce EHR?related
chemotherapy ordering errors. Cancer Med. 2020;9(23):8844-8851. doi:10.1002/cam4.3496.
https://psnet.ahrq.gov/issue/computer-base…
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psnet.ahrq.gov/node/46354/psn-pdf
November 21, 2017 - Controlled trial to improve resident sign-out in a medical
intensive care unit.
November 21, 2017
Nanchal R, Aebly B, Graves G, et al. Controlled trial to improve resident sign-out in a medical intensive
care unit. BMJ Qual Saf. 2017;26(12):987-992. doi:10.1136/bmjqs-2017-006657.
https://psnet.ahrq.gov/issue/contr…
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psnet.ahrq.gov/node/853613/psn-pdf
September 20, 2023 - From battles to burnout: investigating the role of
interphysician conflict in physician burnout.
September 20, 2023
Amick AE, Schrepel C, Bann M, et al. From battles to burnout: investigating the role of interphysician
conflict in physician burnout. Acad Med. 2023;98(9):1076-1082. doi:10.1097/acm.0000000000005226.
…
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psnet.ahrq.gov/node/37452/psn-pdf
January 09, 2008 - A randomized clinical trial to compare the use of safety
net enclosures with standard restraints in agitated
hospitalized patients.
January 9, 2008
Nawaz H, Abbas A, Sarfraz A, et al. A randomized clinical trial to compare the use of safety net enclosures
with standard restraints in agitated hospitalized patients.…
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psnet.ahrq.gov/node/47094/psn-pdf
June 13, 2018 - Polypharmacy and potentially inappropriate medication in
people with dementia: a nationwide study.
June 13, 2018
Kristensen RU, Nørgaard A, Jensen-Dahm C, et al. Polypharmacy and Potentially Inappropriate Medication
in People with Dementia: A Nationwide Study. J Alzheimers Dis. 2018;63(1):383-394. doi:10.3233/JAD-
…