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psnet.ahrq.gov/node/40617/psn-pdf
November 01, 2011 - Increasing medication error reporting rates while
reducing harm through simultaneous cultural and
system-level interventions in an intensive care unit.
November 1, 2011
Abstoss KM, Shaw BE, Owens TA, et al. Increasing medication error reporting rates while reducing harm
through simultaneous cultural and system-lev…
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psnet.ahrq.gov/node/42877/psn-pdf
January 22, 2014 - Identification of poor performance in a national medical
workforce over 11 years: an observational study.
January 22, 2014
Donaldson LJ, Panesar S, McAvoy PA, et al. Identification of poor performance in a national medical
workforce over 11 years: an observational study. BMJ Qual Saf. 2014;23(2):147-52. doi:10.1136…
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psnet.ahrq.gov/node/836809/psn-pdf
March 30, 2022 - Pharmacist transition-of-care services improve patient
satisfaction and decrease hospital readmissions.
March 30, 2022
March KL, Peters MJ, Finch CK, et al. J Pharm Pract. 2022;35(1):86-93.
https://psnet.ahrq.gov/issue/pharmacist-transition-care-services-improve-patient-satisfaction-and-decrease-
hospital
Tr…
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psnet.ahrq.gov/node/47108/psn-pdf
June 06, 2018 - Cognitive bias in clinical practice—nurturing healthy
skepticism among medical students.
June 6, 2018
Bhatti A. Cognitive bias in clinical practice - nurturing healthy skepticism among medical students. Adv Med
Educ Pract. 2018;9:235-237. doi:10.2147/AMEP.S149558.
https://psnet.ahrq.gov/issue/cognitive-bias-clinic…
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psnet.ahrq.gov/primer/telehealth-and-patient-safety
July 27, 2022 - Telehealth and Patient Safety.
Citation Text:
O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/40243/psn-pdf
June 10, 2018 - Preventing medication errors during codes.
June 10, 2018
ISMP Medication Safety Alert! Acute care edition. February 9, 2011;16:1-3.
https://psnet.ahrq.gov/issue/preventing-medication-errors-during-codes
This piece discusses medication errors during emergency resuscitations and outlines risk-reduction
strategies.
…
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psnet.ahrq.gov/node/36491/psn-pdf
January 07, 2011 - Doctors fear criminalization of medical mistakes.
January 7, 2011
Sorrel AL. American Medical News. November 27, 2006.
https://psnet.ahrq.gov/issue/doctors-fear-criminalization-medical-mistakes
This article discusses how the threat of criminal charges for deaths caused by medical mistakes may affect
treatment deci…
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psnet.ahrq.gov/node/35768/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-3
This monthly selection of medication error reports provides examples of problems with drug name
confusion and misspellings, oral medication misadministration, and dispensing dose disc…
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psnet.ahrq.gov/issue/impacts-using-community-health-volunteers-coach-medication-safety-behaviors-among-rural
September 15, 2011 - Study
The impacts of using community health volunteers to coach medication safety behaviors among rural elders with chronic illnesses.
Citation Text:
Wang C-J, Fetzer SJ, Yang Y-C, et al. The impacts of using community health volunteers to coach medication safety behaviors among rural e…
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psnet.ahrq.gov/issue/shame-and-guilt-ems-qualitative-analysis-culture-and-attitudes-prehospital-emergency-care
August 26, 2020 - Study
Shame and guilt in EMS: a qualitative analysis of culture and attitudes in prehospital emergency care.
Citation Text:
Hoff JJ, Zimmerman A, Tupetz A, et al. Shame and guilt in EMS: a qualitative analysis of culture and attitudes in prehospital emergency care. Prehosp Emerg Care. 20…
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psnet.ahrq.gov/issue/enhancing-safe-medication-use-home-care-insights-informal-caregivers
December 02, 2020 - Study
Enhancing safe medication use in home care: insights from informal caregivers.
Citation Text:
Gil-Hernández E, Ballester P, Guilabert M, et al. Enhancing safe medication use in home care: insights from informal caregivers. Front Med (Lausanne). 2024;11:1494771. doi:10.3389/fmed.202…
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psnet.ahrq.gov/issue/apologies-following-adverse-medical-event-importance-focusing-consumers-needs
June 27, 2011 - Study
Apologies following an adverse medical event: the importance of focusing on the consumer's needs.
Citation Text:
Allan A, McKillop D, Dooley J, et al. Apologies following an adverse medical event: The importance of focusing on the consumer's needs. Patient Educ Couns. 2015;98(9):10…
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psnet.ahrq.gov/issue/epidemiology-patterns-care-and-mortality-patients-acute-respiratory-distress-syndrome
August 04, 2021 - Study
Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries.
Citation Text:
Bellani G, Laffey JG, Pham T, et al. Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distres…
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psnet.ahrq.gov/issue/enteral-nutrition-underappreciated-source-patient-safety-events
February 01, 2023 - Study
Enteral nutrition: an underappreciated source of patient safety events.
Citation Text:
Citty SW, Chew M, Hiller LD, et al. Enteral nutrition: an underappreciated source of patient safety events. Nutr Clin Prac. 2024;39(4):784-799. doi:10.1002/ncp.11153.
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psnet.ahrq.gov/issue/developing-implementing-evaluating-electronic-apparent-cause-analysis-across-health-care
February 07, 2018 - Study
Developing, implementing, evaluating electronic apparent cause analysis across a health care system.
Citation Text:
Oster CA, Woods E, Mumma J, et al. Developing, implementing, evaluating electronic apparent cause analysis across a health care system. Jt Comm J Qual Patient Saf. 2…
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psnet.ahrq.gov/issue/scientific-view-global-literature-medical-error-reporting-and-reporting-systems-1977-2021
October 19, 2022 - Review
Scientific view of the global literature on medical error reporting and reporting systems from 1977 to 2021: a bibliometric analysis.
Citation Text:
Ünal A, Seren Intepeler Ş. Scientific view of the global literature on medical error reporting and reporting systems from 1977 to 20…
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psnet.ahrq.gov/issue/building-patient-trust-hospitals-combination-hospital-related-factors-and-health-care
April 14, 2021 - Study
Building patient trust in hospitals: a combination of hospital-related factors and health care clinician behaviors.
Citation Text:
Greene J, Samuel-Jakubos H. Building patient trust in hospitals: a combination of hospital-related factors and health care clinician behaviors. Jt Comm…
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psnet.ahrq.gov/issue/causes-adverse-events-home-mechanical-ventilation-nursing-perspective
November 10, 2021 - Study
Causes of adverse events in home mechanical ventilation: a nursing perspective.
Citation Text:
Lipprandt M, Liedtke W, Langanke M, et al. Causes of adverse events in home mechanical ventilation: a nursing perspective. BMC Nurs. 2022;21(1):264. doi:10.1186/s12912-022-01038-2.
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psnet.ahrq.gov/issue/toward-increased-patient-safety-electronic-communication-medication-information-between
June 23, 2021 - Study
Toward increased patient safety? Electronic communication of medication information between nurses in home health care and general practitioners.
Citation Text:
Lyngstad M, Melby L, Grimsmo A, et al. Toward Increased Patient Safety? Electronic Communication of Medication Informat…
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psnet.ahrq.gov/issue/cardiopulmonary-arrest-and-mortality-trends-and-their-association-rapid-response-system
January 15, 2009 - Study
Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion.
Citation Text:
Chen J, Ou L, Hillman KM, et al. Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion. Med J Aust. 2014;201(3):…