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psnet.ahrq.gov/issue/emergency-medical-services-provider-perceptions-nature-adverse-events-and-near-misses-out
September 09, 2010 - Study
Emergency medical services provider perceptions of the nature of adverse events and near-misses in out-of-hospital care: an ethnographic view.
Citation Text:
Fairbanks RJ, Crittenden CN, O’Gara KG, et al. Emergency Medical Services Provider Perceptions of the Nature of Adverse E…
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psnet.ahrq.gov/issue/impacts-pharmacist-managed-outpatient-clinic-and-chemotherapy-directed-electronic-order-sets
June 18, 2014 - Study
The impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic order sets for monitoring oral chemotherapy.
Citation Text:
Battis B, Clifford L, Huq M, et al. The impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic orde…
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psnet.ahrq.gov/issue/relationship-between-physician-practice-characteristics-and-physician-adoption-electronic
November 13, 2013 - Study
The relationship between physician practice characteristics and physician adoption of electronic health records.
Citation Text:
Bramble JD, Galt KA, Siracuse M, et al. The relationship between physician practice characteristics and physician adoption of electronic health records.…
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psnet.ahrq.gov/issue/patients-use-internet-technology-report-when-things-go-wrong
July 21, 2009 - Study
Patients use an internet technology to report when things go wrong.
Citation Text:
Wasson JH, MacKenzie TA, Hall M. Patients use an internet technology to report when things go wrong. Qual Saf Health Care. 2007;16(3):213-5.
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Google Scholar PubMe…
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psnet.ahrq.gov/issue/critical-events-during-land-based-interfacility-transport
April 15, 2019 - Study
Critical events during land-based interfacility transport.
Citation Text:
Singh JM, MacDonald RD, Ahghari M. Critical events during land-based interfacility transport. Ann Emerg Med. 2014;64(1):9-15.e2. doi:10.1016/j.annemergmed.2013.12.009.
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psnet.ahrq.gov/issue/thresholds-rules-and-defensive-strategies-how-physicians-learn-their-prior-diagnosis-related
April 15, 2020 - Study
Thresholds, rules and defensive strategies: how physicians learn from their prior diagnosis-related experiences.
Citation Text:
Donner-Banzhoff N, Müller B, Beyer M, et al. Thresholds, rules and defensive strategies: how physicians learn from their prior diagnosis-related experienc…
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psnet.ahrq.gov/issue/applying-human-factors-engineering-address-telemetry-alarm-problem-large-medical-center
February 10, 2021 - Study
Applying human factors engineering to address the telemetry alarm problem in a large medical center.
Citation Text:
Patterson ES, Rayo MF, Edworthy JR, et al. Applying human factors engineering to address the telemetry alarm problem in a large medical center. Hum Factors. 2022;64(1…
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psnet.ahrq.gov/issue/evaluation-electronic-health-record-implementation-pharmacist-interventions-related-oral
January 25, 2023 - Study
Evaluation of electronic health record implementation on pharmacist interventions related to oral chemotherapy management.
Citation Text:
Finn A, Bondarenka C, Edwards K, et al. Evaluation of electronic health record implementation on pharmacist interventions related to oral chemot…
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psnet.ahrq.gov/issue/crying-wolf-alarm-safety-and-management-paediatrics-scoping-review
April 24, 2018 - Review
Crying wolf, alarm safety and management in paediatrics: a scoping review.
Citation Text:
Cole R, Roderick G, Cheema O, et al. Crying wolf, alarm safety and management in paediatrics: a scoping review. J Adv Nurs. 2024;Epub Sep 25. doi:10.1111/jan.16398.
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psnet.ahrq.gov/issue/more-1000-preventable-deaths-day-too-many-need-improve-patient-safety
September 02, 2016 - Congressional Testimony
More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety.
Citation Text:
More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety. Hearing Before the Subcommittee on Primary Health and Aging, 113th Co…
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psnet.ahrq.gov/issue/reporting-medical-errors-improve-patient-safety-survey-physicians-teaching-hospitals
February 24, 2011 - September 26, 2018
Medication errors with electronic prescribing (eP): two views of the
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psnet.ahrq.gov/issue/diagnostic-errors-health-disparities-and-artificial-intelligence-combination-health-or-harm
December 09, 2020 - May 12, 2021
FDA Advise-ERR: reported medication errors with Veklury (remdesivir) emergency
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psnet.ahrq.gov/issue/disclosing-medical-errors-patients-attitudes-and-practices-physicians-and-trainees
February 15, 2011 - August 30, 2011
Pharmacy student knowledge and communication of medication errors.
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psnet.ahrq.gov/issue/systematic-workup-transfusion-reactions-reveals-passive-co-reporting-handling-errors
December 21, 2016 - September 24, 2016
Descriptive analysis on disproportionate medication errors and associated
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psnet.ahrq.gov/web-mm/dressed-failure
September 01, 2011 - March 4, 2015
Unit-based clinical pharmacists' prevention of serious medication errors
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_training.pptx
December 01, 2017 - Treatment
(1995 – 2004)
Root Causes of Sentinel Events
(All Categories, 1994 – 2005)
Root Causes of Medication … Errors
(1995 – 2004)
Science of
Improving Patient Safety ‹#›
AHRQ Safety Program … errors, delays in treatment, ventilator events, and healthcare-associated infections.
16
Basic Process … you would not want to happen again—an unsafe condition, a patient fall, a venous thromboembolism, a medication … error, a surgical site infection, wrong-site surgery, missing equipment, nursing time spent away from
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psnet.ahrq.gov/node/40802/psn-pdf
January 01, 2012 - Nurses' clinical reasoning: processes and practices of
medication safety.
December 15, 2011
Dickson GL, Flynn L. Nurses' clinical reasoning: processes and practices of medication safety. Qual Health
Res. 2012;22(1):3-16. doi:10.1177/1049732311420448.
https://psnet.ahrq.gov/issue/nurses-clinical-reasoning-processes…
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psnet.ahrq.gov/issue/emergency-preparedness-be-ready-unanticipated-electronic-health-record-ehr-downtime
April 20, 2022 - February 23, 2022
During the pandemic, aspire to identify and prevent medication errors
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psnet.ahrq.gov/topics-0
March 03, 2025 - Thromboembolism Go to this topic
Medication Safety Go to this topic
Medication … Errors/Preventable Adverse Drug Events Go to this topic
Administration Errors Go to this
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psnet.ahrq.gov/issue/readiness-report-medical-treatment-errors-effects-safety-procedures-safety-information-and
July 11, 2007 - December 29, 2014
Medication-error reporting and pharmacy resident experience during