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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45717/psn-pdf
    July 21, 2017 - What have we learnt after 15 years of research into the 'weekend effect'? July 21, 2017 Bray BD, Steventon A. What have we learnt after 15 years of research into the 'weekend effect'? BMJ Qual Saf. 2017;26(8):607-610. doi:10.1136/bmjqs-2016-005793. https://psnet.ahrq.gov/issue/what-have-we-learnt-after-15-years-re…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44702/psn-pdf
    December 16, 2015 - Alarm fatigue: impacts on patient safety. December 16, 2015 Ruskin KJ, Hueske-Kraus D. Alarm fatigue: impacts on patient safety. Curr Opin Anaesthesiol. 2015;28(6):685-690. doi:10.1097/ACO.0000000000000260. https://psnet.ahrq.gov/issue/alarm-fatigue-impacts-patient-safety Alarm fatigue is a recognized safety conce…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43355/psn-pdf
    July 23, 2014 - Nearing zero...reducing grade C medication errors. July 23, 2014 Cockerham J, Figueroa-Altmann A, Foxen C, et al. Nearing zero..reducing grade C medication errors. Nurs Manage. 2014;45(7):26-31. doi:10.1097/01.NUMA.0000451033.38845.d3. https://psnet.ahrq.gov/issue/nearing-zeroreducing-grade-c-medication-errors Thi…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40530/psn-pdf
    September 25, 2011 - Patient safety factors in children dying in a paediatric intensive care unit (PICU): a case notes review study. September 25, 2011 Monroe K, Wang D, Vincent CA, et al. Patient safety factors in children dying in a paediatric intensive care unit (PICU): a case notes review study. BMJ Qual Saf. 2011;20(10):863-8. do…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43284/psn-pdf
    November 28, 2016 - Parental involvement in the preoperative surgical safety checklist is welcomed by both parents and staff. November 28, 2016 Corbally MT, Tierney E. Parental involvement in the preoperative surgical safety checklist is welcomed by both parents and staff. Int J Pediatr. 2014;2014:791490. doi:10.1155/2014/791490. htt…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41193/psn-pdf
    August 02, 2012 - Medicaid, hospital financial stress, and the incidence of adverse medical events for children. August 2, 2012 Smith RB, Dynan L, Fairbrother G, et al. Medicaid, hospital financial stress, and the incidence of adverse medical events for children. Health Serv Res. 2012;47(4):1621-41. doi:10.1111/j.1475-6773.2012.0138…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47824/psn-pdf
    May 20, 2019 - Exploring the human factors of prescribing errors in paediatric intensive care units. May 20, 2019 Sutherland A, Ashcroft DM, Phipps D. Exploring the human factors of prescribing errors in paediatric intensive care units. Arch Dis Child. 2019;104(6):588-595. doi:10.1136/archdischild-2018-315981. https://psnet.ahrq…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44989/psn-pdf
    July 01, 2016 - Can medical record reviewers reliably identify errors and adverse events in the ED? July 1, 2016 Klasco RS, Wolfe RE, Lee T, et al. Can medical record reviewers reliably identify errors and adverse events in the ED? Am J Emerg Med. 2016;34(6):1043-8. doi:10.1016/j.ajem.2016.03.001. https://psnet.ahrq.gov/issue/can…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45281/psn-pdf
    September 01, 2016 - Screen flashes and pop-up reminders: 'alert fatigue' spreads through medicine. September 1, 2016 Luthra S. Kaiser Health News. June 15, 2016. https://psnet.ahrq.gov/issue/screen-flashes-and-pop-reminders-alert-fatigue-spreads-through-medicine Alert fatigue is known to contribute to medical error. This news article…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38804/psn-pdf
    July 22, 2009 - Tenfold therapeutic dosing errors in young children reported to US poison control centers. July 22, 2009 Crouch BI, Caravati M, Moltz E. Tenfold therapeutic dosing errors in young children reported to U.S. poison control centers. Am J Health Syst Pharm. 2009;66(14):1292-6. doi:10.2146/080377. https://psnet.ahrq.go…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47122/psn-pdf
    June 13, 2018 - Intravenous chemotherapy compounding errors in a follow-up pan-Canadian observational study. June 13, 2018 Gilbert RE, Kozak MC, Dobish RB, et al. Intravenous Chemotherapy Compounding Errors in a Follow-Up Pan-Canadian Observational Study. J Oncol Pract. 2018;14(5):e295-e303. doi:10.1200/JOP.17.00007. https://psne…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74046/psn-pdf
    January 01, 2022 - Racial disparities in child abuse medicine. November 3, 2021 Rosenthal CM, Parker DM, Thompson LA. Racial disparities in child abuse medicine. JAMA Pediatr. 2022;176(2):119-120. doi:10.1001/jamapediatrics.2021.3601. https://psnet.ahrq.gov/issue/racial-disparities-child-abuse-medicine The care of child abuse victim…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45423/psn-pdf
    September 27, 2016 - Lost in translation: impact of language barriers on children's healthcare. September 27, 2016 Goenka PK. Lost in translation: impact of language barriers on children's healthcare. Curr Opin Pediatr. 2016;28(5):659-666. doi:10.1097/MOP.0000000000000404. https://psnet.ahrq.gov/issue/lost-translation-impact-language-…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38777/psn-pdf
    March 04, 2011 - Perceptions of standards-based electronic prescribing systems as implemented in outpatient primary care: a physician survey. March 4, 2011 Wang J, Patel MH, Schueth AJ, et al. Perceptions of standards-based electronic prescribing systems as implemented in outpatient primary care: a physician survey. J Am Med Infor…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72659/psn-pdf
    January 20, 2021 - Association between paediatric intraoperative anaesthesia handover and adverse postoperative outcomes. January 20, 2021 Kannampallil TG, Lew D, Pfeifer EE, et al. Association between paediatric intraoperative anaesthesia handover and adverse postoperative outcomes. BMJ Qual Saf. 2021;30(9):755-763. doi:10.1136/bmj…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34730/psn-pdf
    October 29, 2013 - Medication Errors. 2nd ed. October 29, 2013 Cohen MR, ed. Washington DC: American Pharmacists Association; 2007. https://psnet.ahrq.gov/issue/medication-errors-2nd-ed Cohen, executive director of the Institute for Safe Medication Practices (ISMP), combined 25 years of experience as a leader in medication safety wi…
  17. Written Statement (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-141-written-statement.pdf
    June 02, 2025 - Written Statement To Whom It May Concern: As one of the creators of the Pediatric Medical Complexity Algorithm (PMCA), I guarantee that should the U.S. Department ofHealth and Human Services accept PMCA for the 2014 and/or 2015 Improved Core Measure Sets, full measure specifications for PMCA will be subject to p…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44888/psn-pdf
    April 06, 2016 - Transforming the morbidity and mortality conference to promote safety and quality in a PICU. April 6, 2016 Cifra CL, Bembea MM, Fackler JC, et al. Transforming the morbidity and mortality conference to promote safety and quality in a PICU. Crit Care Med. 2016;17(1):58-66. doi:10.1097/PCC.0000000000000539. https://…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43030/psn-pdf
    March 26, 2014 - Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors. March 26, 2014 ISMP Medication Safety Alert! Acute care edition. March 13, 2014;19:1-2,4-5.   https://psnet.ahrq.gov/issue/recommendations-practitioners-and-manufacturers-address-system-based- causes-vaccine-…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46909/psn-pdf
    August 01, 2018 - Guidance on Safe Medical Staffing: Report of a Working Party. August 1, 2018 London, UK: Royal College of Physicians; 2018. ISBN: 9781860167270. https://psnet.ahrq.gov/issue/guidance-safe-medical-staffing-report-working-party Lack of appropriate staffing can diminish the safety and effectiveness of medical service…