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psnet.ahrq.gov/node/851348/psn-pdf
July 12, 2023 - Widespread misinterpretation of advance directives and
Portable Orders for Life-Sustaining Treatments threatens
patient safety and causes undertreatment and
overtreatment.
July 12, 2023
Mirarchi FL, Pope TM. Widespread misinterpretation of advance directives and Portable Orders for Life-
Sustaining Treatments thr…
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psnet.ahrq.gov/node/41572/psn-pdf
October 29, 2012 - Diagnostic errors in the intensive care unit: a systematic
review of autopsy studies.
October 29, 2012
Winters BD, Custer J, Galvagno SM, et al. Diagnostic errors in the intensive care unit: a systematic review
of autopsy studies. BMJ Qual Saf. 2012;21(11):894-902. doi:10.1136/bmjqs-2012-000803.
https://psnet.ahrq…
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psnet.ahrq.gov/node/41250/psn-pdf
December 21, 2014 - Disclosure of "nonharmful" medical errors and other
events: duty to disclose.
December 21, 2014
Chamberlain CJ, Koniaris LG, Wu AW, et al. Disclosure of "nonharmful" medical errors and other events:
duty to disclose. Arch Surg. 2012;147(3):282-6. doi:10.1001/archsurg.2011.1005.
https://psnet.ahrq.gov/issue/disclos…
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psnet.ahrq.gov/node/42178/psn-pdf
April 10, 2013 - Outside case review of surgical pathology for referred
patients: the impact on patient care.
April 10, 2013
Swapp RE, Aubry MC, Salomão DR, et al. Outside case review of surgical pathology for referred patients:
the impact on patient care. Arch Pathol Lab Med. 2013;137(2):233-40. doi:10.5858/arpa.2012-0088-OA.
htt…
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psnet.ahrq.gov/node/862991/psn-pdf
February 21, 2024 - Exploring the role of guidelines in contributing to
medication errors: a descriptive analysis of national
patient safety incident data.
February 21, 2024
Jones MD, Liu S, Powell F, et al. Exploring the role of guidelines in contributing to medication errors: a
descriptive analysis of national patient safety incide…
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psnet.ahrq.gov/node/37386/psn-pdf
January 06, 2017 - Medication reconciliation in ambulatory oncology.
January 6, 2017
Weingart SN, Cleary A, Seger AC, et al. Medication reconciliation in ambulatory oncology. Jt Comm J Qual
Patient Saf. 2007;33(12):750-7.
https://psnet.ahrq.gov/issue/medication-reconciliation-ambulatory-oncology
The Joint Commission mandates systems…
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psnet.ahrq.gov/node/43567/psn-pdf
October 21, 2016 - National Action Plan for Adverse Drug Event Prevention.
October 21, 2016
Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health
and Human Services; September 2014.
https://psnet.ahrq.gov/issue/national-action-plan-adverse-drug-event-prevention
This national action pla…
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psnet.ahrq.gov/node/60539/psn-pdf
July 10, 2017 - Understanding facilitators and barriers to care
transitions: insights from Project ACHIEVE Site Visits.
July 10, 2017
Scott AM, Li J, Oyewole-Eletu S, et al. Understanding facilitators and barriers to care transitions: insights
from Project ACHIEVE Site Visits. Jt Comm J Qual Patient Saf. 2017;43(9):433-447.
doi:1…
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psnet.ahrq.gov/node/60185/psn-pdf
April 01, 2020 - Associations between stopping prescriptions for opioids,
length of opioid treatment, and overdose or suicide
deaths in US veterans: observational evaluation.
April 1, 2020
Oliva EM, Bowe T, Manhapra A, et al. Associations between stopping prescriptions for opioids, length of
opioid treatment, and overdose or suici…
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psnet.ahrq.gov/node/39581/psn-pdf
January 03, 2017 - An implementation strategy for a multicenter pediatric
rapid response system in Ontario.
January 3, 2017
Buist MD, Shearer W. Rapid Response Systems: A Mandatory System of Care or an Optional Extra for
Bedside Clinical Staff? The Joint Commission Journal on Quality and Patient Safety. 2016;36(6).
doi:10.1016/s1553…
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psnet.ahrq.gov/node/47561/psn-pdf
February 22, 2019 - "Change is what can actually make the tough times
better": a patient-centred patient safety intervention
delivered in collaboration with hospital volunteers.
February 22, 2019
Louch G, Mohammed MA, Hughes L, et al. "Change is what can actually make the tough times better": A
patient-centred patient safety interven…
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psnet.ahrq.gov/node/73364/psn-pdf
January 01, 2022 - Impact of opioid administration in the intensive care unit
and subsequent use in opioid-naïve patients.
June 9, 2021
Krancevich NM, Belfer JJ, Draper HM, et al. Impact of opioid administration in the intensive care unit and
subsequent use in opioid-naïve patients. Ann Pharmacother. 2022;56(1):52-59.
doi:10.1177/10…
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psnet.ahrq.gov/node/836719/psn-pdf
March 09, 2022 - Prevalence and factors associated with patient-requested
corrections to the medical record through use of a patient
portal: findings from a national survey.
March 9, 2022
Nguyen OT, Hong Y-R, Alishahi Tabriz A, et al. Prevalence and factors associated with patient-requested
corrections to the medical record throug…
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psnet.ahrq.gov/node/37776/psn-pdf
January 31, 2011 - Barcoded medication administration: a last line of
defense.
January 31, 2011
Cescon DW, Etchells E. Barcoded medication administration: a last line of defense. JAMA.
2008;299(18):2200-2. doi:10.1001/jama.299.18.2200.
https://psnet.ahrq.gov/issue/barcoded-medication-administration-last-line-defense
Barcoding techn…
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psnet.ahrq.gov/node/60591/psn-pdf
June 17, 2020 - National trends in the safety performance of electronic
health record systems from 2009 to 2018.
June 17, 2020
Classen DC, Holmgren AJ, Co Z, et al. National trends in the safety performance of electronic health record
systems from 2009 to 2018. JAMA Netw Open. 2020;3(5). doi:10.1001/jamanetworkopen.2020.5547.
htt…
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psnet.ahrq.gov/node/866908/psn-pdf
October 09, 2024 - Risk factors for wrong-site surgery: a study of 1,166
reports of informed consent and schedule errors.
October 9, 2024
Taylor MA, Yonash RA. Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent
and schedule errors. Patient Safety. 2024;6(1):1-11. doi:10.33940/001c.117084.
https://psnet…
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psnet.ahrq.gov/node/45710/psn-pdf
December 22, 2017 - Our current approach to root cause analysis: is it
contributing to our failure to improve patient safety?
December 22, 2017
Kellogg KM, Hettinger Z, Shah M, et al. Our current approach to root cause analysis: is it contributing to our
failure to improve patient safety? BMJ Qual Saf. 2017;26(5):381-387. doi:10.1136/…
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psnet.ahrq.gov/node/837737/psn-pdf
July 27, 2022 - Patients' willingness and ability to identify and respond to
errors in their personal health records: mixed methods
analysis of cross-sectional survey data.
July 27, 2022
Lear R, Freise L, Kybert M, et al. Patients' willingness and ability to identify and respond to errors in their
personal health records: mixed m…
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psnet.ahrq.gov/node/46459/psn-pdf
August 20, 2018 - Readiness of US general surgery residents for
independent practice.
August 20, 2018
George BC, Bohnen JD, Williams RG, et al. Readiness of US General Surgery Residents for Independent
Practice. Ann Surg. 2017;266(4):582-594. doi:10.1097/SLA.0000000000002414.
https://psnet.ahrq.gov/issue/readiness-us-general-surger…
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psnet.ahrq.gov/node/42232/psn-pdf
May 08, 2013 - The Measurement and Monitoring of Safety.
May 8, 2013
Vincent C, Burnett S, Carthey J. London, UK: Health Foundation; April 2013. ISBN: 9781906461447.
https://psnet.ahrq.gov/issue/measurement-and-monitoring-safety
Despite great effort, health care organizations are still learning how to identify safety problems, es…