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psnet.ahrq.gov/primer/pharmacists-role-medication-safety
March 14, 2018 - Correct medication use occurs when the "five rights" are followed, meaning the right dose of the right
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psnet.ahrq.gov/node/60980/psn-pdf
January 01, 2022 - Analysis of risk factors for patient safety events occurring
in the emergency department.
October 7, 2020
Alsabri M, Boudi Z, Zoubeidi T, et al. Analysis of risk factors for patient safety events occurring in the
emergency department. J Patient Saf. 2022;18(1):e124-e135. doi:10.1097/pts.0000000000000715.
https://p…
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psnet.ahrq.gov/issue/potentially-severe-incidents-during-interhospital-transport-critically-ill-patients
October 26, 2022 - Study
Potentially severe incidents during interhospital transport of critically ill patients, frequently occurring but rarely reported: a prospective study.
Citation Text:
Eiding H, Røise O, Kongsgaard UE. Potentially severe incidents during interhospital transport of critically ill pati…
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psnet.ahrq.gov/node/41989/psn-pdf
September 27, 2016 - Tapping front-line knowledge: identifying problems as
they occur helps enhance patient safety.
September 27, 2016
Luther K, Resar RK. Tapping front-line knowledge: identifying problems as they occur helps enhance
patient safety. Healthcare executive. 2013;28(1):84-7.
https://psnet.ahrq.gov/issue/tapping-front-line…
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psnet.ahrq.gov/node/37533/psn-pdf
April 22, 2011 - Systematic evaluation of errors occurring during the
preparation of intravenous medication.
April 22, 2011
Parshuram CS, To T, Seto W, et al. Systematic evaluation of errors occurring during the preparation of
intravenous medication. CMAJ. 2008;178(1):42-8. doi:10.1503/cmaj.061743.
https://psnet.ahrq.gov/issue/sys…
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psnet.ahrq.gov/node/39252/psn-pdf
August 08, 2010 - Where errors occur in the preparation and administration
of intravenous medicines: a systematic review and
Bayesian analysis.
August 8, 2010
McDowell SE, Mt-Isa S, Ashby D, et al. Where errors occur in the preparation and administration of
intravenous medicines: a systematic review and Bayesian analysis. Qual Saf …
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psnet.ahrq.gov/node/34607/psn-pdf
June 12, 2018 - A clinician's guide to surgical fires: how they occur, how
to prevent them, how to put them out.
June 12, 2018
A clinician's guide to surgical fires. How they occur, how to prevent them, how to put them out. Health
Devices. 2003;32(1):5-24.
https://psnet.ahrq.gov/issue/clinicians-guide-surgical-fires-how-they-occu…
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psnet.ahrq.gov/node/35876/psn-pdf
June 18, 2013 - External Inquiry into the adverse incident that occurred at
Queen's Medical Centre, Nottingham, 4th January 2001.
June 18, 2013
Toft B. London, UK; Crown Copyright: 2001.
https://psnet.ahrq.gov/issue/external-inquiry-adverse-incident-occurred-queens-medical-centre-nottingham-
4th-january-2001
This UK Department o…
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psnet.ahrq.gov/node/42993/psn-pdf
March 19, 2014 - Baccalaureate nursing students' accounts of medical
mistakes occurring in the clinical setting: implications for
curricula.
March 19, 2014
Noland CM. Baccalaureate nursing students' accounts of medical mistakes occurring in the clinical setting:
implications for curricula. J Nurs Educ. 2014;53(3):S34-7. doi:10.392…
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psnet.ahrq.gov/node/37156/psn-pdf
October 06, 2011 - Preventable harm occurring to critically ill children.
October 6, 2011
Larsen G, Donaldson AE, Parker HB, et al. Preventable harm occurring to critically ill children. Pediatr Crit
Care Med. 2007;8(4):331-336.
https://psnet.ahrq.gov/issue/preventable-harm-occurring-critically-ill-children
This retrospective cohort…
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psnet.ahrq.gov/issue/why-simulation-matters-systematic-review-medical-errors-occurring-during-simulated-health
September 25, 2019 - Review
Why simulation matters: a systematic review on medical errors occurring during simulated health care.
Citation Text:
Bokka L, Ciuffo F, Clapper TC. Why simulation matters: a systematic review on medical errors occurring during simulated health care. J Patient Saf. 2024;20(2):110-1…
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psnet.ahrq.gov/node/39961/psn-pdf
March 08, 2015 - When errors occur.
March 8, 2015
Wetzel TG. When errors occur, 'I'm sorry' is a big step, but just the first. Hospitals & health networks.
2010;84(10):41-2, 44, 2.
https://psnet.ahrq.gov/issue/when-errors-occur
This article describes how hospital responses to adverse events have affected disclosure process
strate…
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psnet.ahrq.gov/issue/where-errors-occur-preparation-and-administration-intravenous-medicines-systematic-review-and
June 30, 2011 - Review
Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis.
Citation Text:
McDowell SE, Mt-Isa S, Ashby D, et al. Where errors occur in the preparation and administration of intravenous medicines: a systematic rev…
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psnet.ahrq.gov/node/38992/psn-pdf
April 16, 2018 - Safe patient outcomes occur with timely, standardized
communication of critical values.
April 16, 2018
https://psnet.ahrq.gov/issue/safe-patient-outcomes-occur-timely-standardized-communication-critical-
values
This article reports on failures surrounding critical test results and describes mechanisms to standardi…
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psnet.ahrq.gov/node/39743/psn-pdf
October 13, 2010 - Anatomy and pathophysiology of errors occurring in
clinical radiology practice.
October 13, 2010
Brook OR, O'Connell AM, Thornton E, et al. Quality initiatives: anatomy and pathophysiology of errors
occurring in clinical radiology practice. Radiographics. 2010;30(5):1401-10. doi:10.1148/rg.305105013.
https://psnet…
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psnet.ahrq.gov/node/37155/psn-pdf
October 06, 2011 - Classification of adverse events occurring in a surgical
intensive care unit.
October 6, 2011
Frankel H, Sperry J, Kaplan L, et al. Classification of adverse events occurring in a surgical intensive care
unit. Am J Surg. 2007;194(3):328-32.
https://psnet.ahrq.gov/issue/classification-adverse-events-occurring-surgi…
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psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
June 16, 2021 - mental strengths and weaknesses of clinicians and how these affect whether or not a medication error occurs
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psnet.ahrq.gov/node/37196/psn-pdf
June 06, 2018 - Fatal 1,000-fold overdoses can occur, particularly in
neonates, by transposing mcg and mg.
June 6, 2018
ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4.
https://psnet.ahrq.gov/issue/fatal-1000-fold-overdoses-can-occur-particularly-neonates-transposing-mcg-
and-mg
This article analyzes a…
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - , and unsafe conditions, and it will be standardized throughout the hospital regardless of where it occurs … Hence the information will be clinically comparable no matter where in the institution an event occurs—or … even in what institution it occurs.
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psnet.ahrq.gov/perspective/becoming-patient-safety-organization
July 01, 2011 - , and unsafe conditions, and it will be standardized throughout the hospital regardless of where it occurs … Hence the information will be clinically comparable no matter where in the institution an event occurs—or … even in what institution it occurs.