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psnet.ahrq.gov/node/849130/psn-pdf
May 17, 2023 - Comparing perspectives on organisational silence: an
analysis of the Gosport inquiry.
May 17, 2023
Powell M. J Health Org Manag. 2023;37(1):67-83.
https://psnet.ahrq.gov/issue/comparing-perspectives-organisational-silence-analysis-gosport-inquiry
Individual, team, and organizational willingness to identify and add…
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psnet.ahrq.gov/node/854637/psn-pdf
October 18, 2023 - A scoping review of clinical handover mnemonic devices.
October 18, 2023
Yung AHW, Pak CS, Watson B. A scoping review of clinical handover mnemonic devices. Int J Qual Health
Care. 2023;35(3):mzad065. doi:10.1093/intqhc/mzad065.
https://psnet.ahrq.gov/issue/scoping-review-clinical-handover-mnemonic-devices
Cogniti…
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psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
April 26, 2023 - We did a ten-year review study, looking at death and harm related to administration of opioids, and no … one died in that inpatient setting from opioids when using this system. … A lot of patients in the hospital are on opioids. … This is the idea of serious but treatable complications, and respiratory arrests due to opioids are a
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psnet.ahrq.gov/node/60186/psn-pdf
April 01, 2020 - Eleven basic procedures/practices for dental patient
safety.
April 1, 2020
Perea-Pérez B, Labajo-González E, Acosta-Gío AE, et al. Eleven basic procedures/practices for dental
patient safety. J Patient Saf. 2020;16(1). doi:10.1097/pts.0000000000000234.
https://psnet.ahrq.gov/issue/eleven-basic-procedurespractices-…
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psnet.ahrq.gov/node/48045/psn-pdf
June 05, 2019 - Obstetric practice guidelines: labor's love lost?
June 5, 2019
Cohen WR, Friedman EA. Obstetric practice guidelines: labor's love lost? J Matern Fetal Neonatal Med.
2019;32(9):1567-1570. doi:10.1080/14767058.2017.1406474.
https://psnet.ahrq.gov/issue/obstetric-practice-guidelines-labors-love-lost
Guidelines play a…
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psnet.ahrq.gov/node/46254/psn-pdf
October 09, 2017 - Using risk stratification to reduce medical errors in
cervical cancer prevention.
October 9, 2017
Perkins RB, Cain JM, Feldman S. Using Risk Stratification to Reduce Medical Errors in Cervical Cancer
Prevention. JAMA Intern Med. 2017;177(10):1411-1412. doi:10.1001/jamainternmed.2017.3999.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/42663/psn-pdf
October 16, 2023 - Patient Safety: A Case-based Innovative Playbook for
Safer Care. Second Edition.
October 16, 2023
Agrawal A, Bhatt J, eds. Cham, Switzerland, Springer Nature; 2023. ISBN: 9783031359330.
https://psnet.ahrq.gov/issue/patient-safety-case-based-innovative-playbook-safer-care-second-edition
This publication describes a…
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psnet.ahrq.gov/node/867754/psn-pdf
March 12, 2025 - Decision fatigue in hospital settings: a scoping review.
March 12, 2025
Perry K, Jones S, Stumpff JC, et al. Decision fatigue in hospital settings: a scoping review. J Hosp Med.
2024;Epub Nov 11. doi:10.1002/jhm.13550.
https://psnet.ahrq.gov/issue/decision-fatigue-hospital-settings-scoping-review
Production pressu…
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psnet.ahrq.gov/node/867021/psn-pdf
October 23, 2024 - Blind Spots: When Medicine Gets It Wrong, and What It
Means for Our Health.
October 23, 2024
Makary M. Blind Spots: When Medicine Gets It Wrong, And What It Means For Our Health. New York, NY:
Bloomsbury Publishing; 2024. ISBN 9781639735310.
https://psnet.ahrq.gov/issue/blind-spots-when-medicine-gets-it-wrong-and-…
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psnet.ahrq.gov/issue/states-targeting-reduction-infections-engagement-strive
June 12, 2024 - Special or Theme Issue
States Targeting Reduction in Infections via Engagement (STRIVE).
Citation Text:
States Targeting Reduction in Infections via Engagement (STRIVE). Ann Intern Med. 2019;171(7_Suppl):s1-s82.
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psnet.ahrq.gov/node/851067/psn-pdf
June 28, 2023 - Assessing medication safety in settings not designated
solely for pediatric patients.
June 28, 2023
ISMP Medication Safety Alert! Acute care edition. June 15, 2023;28(12);1-5.
https://psnet.ahrq.gov/issue/assessing-medication-safety-settings-not-designated-solely-pediatric-patients
Pediatric patients are at increa…
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psnet.ahrq.gov/node/47217/psn-pdf
June 27, 2018 - Drug shortages roundtable: minimizing the impact on
patient care.
June 27, 2018
Drug shortages roundtable: Minimizing the impact on patient care. Am J Health Syst Pharm.
2018;75(11):816-820. doi:10.2146/ajhp180048.
https://psnet.ahrq.gov/issue/drug-shortages-roundtable-minimizing-impact-patient-care
This commenta…
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psnet.ahrq.gov/node/41635/psn-pdf
January 18, 2013 - Improvement in the detection of adverse drug events by
the use of electronic health and prescription records: an
evaluation of two trigger tools.
January 18, 2013
Nwulu U, Nirantharakumar K, Odesanya R, et al. Improvement in the detection of adverse drug events by
the use of electronic health and prescription reco…
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psnet.ahrq.gov/perspective/patient-safety-primary-care
January 31, 2020 - These predominantly relate to inconsistent practices driving the prescribing of opioids and antibiotics
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psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
April 26, 2023 - We did a ten-year review study, looking at death and harm related to administration of opioids, and no … one died in that inpatient setting from opioids when using this system. … A lot of patients in the hospital are on opioids. … This is the idea of serious but treatable complications, and respiratory arrests due to opioids are a
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psnet.ahrq.gov/node/866323/psn-pdf
July 17, 2024 - AHRQ-Funded Patient Safety Project Highlights:
Improving Patient Safety by Enhancing Care
Coordination.
July 17, 2024
Rockville, MD: Agency for Healthcare Research and Quality; June 2024. AHRQ Pub. No. 24-0017-2-EF.
https://psnet.ahrq.gov/issue/ahrq-funded-patient-safety-project-highlights-improving-patient-safety…
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psnet.ahrq.gov/node/46861/psn-pdf
February 28, 2018 - Special K with no license to kill: accidental ketamine
overdose on induction of general anesthesia.
February 28, 2018
Warner LL, Smischney N. Accidental Ketamine Overdose on Induction of General Anesthesia. Am J Case
Rep. 2018;19:10-12.
https://psnet.ahrq.gov/issue/special-k-no-license-kill-accidental-ketamine-ove…
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psnet.ahrq.gov/node/73714/psn-pdf
September 15, 2021 - Evaluation of Quality, Safety, and Value in Veterans
Health Administration Facilities, FY 2020.
September 15, 2021
Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.
https://psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-f…
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psnet.ahrq.gov/node/866108/psn-pdf
June 12, 2024 - Child age and risk of medication error: a multisite
children's hospital study.
June 12, 2024
Badgery-Parker T, Li L, Fitzpatrick E, et al. Child age and risk of medication error: a multisite children's
hospital study. J Pediatr. 2024;272:114087. doi:10.1016/j.jpeds.2024.114087.
https://psnet.ahrq.gov/issue/child-a…
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psnet.ahrq.gov/node/73982/psn-pdf
October 20, 2021 - US emergency department visits attributed to medication
harms, 2017-2019.
October 20, 2021
Budnitz DS, Shehab N, Lovegrove MC, et al. US emergency department visits attributed to medication
harms, 2017-2019. JAMA. 2021;326(13):1299. doi:10.1001/jama.2021.13844.
https://psnet.ahrq.gov/issue/us-emergency-department-…