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psnet.ahrq.gov/issue/sudden-death-lung-embolism-after-inadvertent-infusion-zinc-oxide-shake-lotion
January 12, 2022 - Commentary
A sudden death with lung embolism after inadvertent infusion of zinc oxide shake lotion.
Citation Text:
Pragst F, Correns A, Priem F, et al. A sudden death with lung embolism after inadvertent infusion of zinc oxide shake lotion. Forensic Sci Int. 2007;170(2-3):207-12.
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psnet.ahrq.gov/issue/hospital-checklists-are-meant-save-lives-so-why-do-they-often-fail
July 31, 2013 - Newspaper/Magazine Article
Hospital checklists are meant to save lives—so why do they often fail?
Citation Text:
Anthes E. Hospital checklists are meant to save lives - so why do they often fail? Nature. 2015;523(7562):516-8. doi:10.1038/523516a.
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DOI G…
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psnet.ahrq.gov/issue/influence-tall-man-lettering-errors-visual-perception-recognition-written-drug-names
December 19, 2017 - Study
The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names.
Citation Text:
Darker IT, Gerret D, Filik R, et al. The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names. Ergono…
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - SPOTLIGHT CASE
Getting to the Root of the Matter
Citation Text:
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Google Schola…
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Getting to the Root of the Matter
June 1, 2005
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/getting-root-matter
Case Objectives
Appreciate the goals and limitations of root cause analysis
Outline the steps to conduct root cause analysis
The Case
A…
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psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
November 01, 2003 - factors associated with safety climate, patient satisfaction and self-reported medicines adherence in community … pharmacies.
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psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance
Measurement Tracking, and Performance Feedback
February 28, 2024
https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-
and-performance
Summary
To improve patient care and outcomes in the intensive care unit (ICU…
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - Personal Health Literacy
August 30, 2023
Bakerjian D. Personal Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/personal-health-literacy
Originally published in July 2017 by researchers at the University of California, San Francisco. Updated in
August 2023 by Deb Bakerjian, PhD, RN, APRN, FAA…
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psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
May 26, 2021 - SPOTLIGHT CASE
When the Indications for Drug Administration Blur
Citation Text:
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging
July 8, 2022
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
The Cases
Case #1: A 42-year-old woman admitted with…
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psnet.ahrq.gov/issue/limited-health-literacy-barrier-medication-reconciliation-ambulatory-care
March 24, 2010 - Study
Limited health literacy is a barrier to medication reconciliation in ambulatory care.
Citation Text:
Persell SD, Osborn CY, Richard R, et al. Limited health literacy is a barrier to medication reconciliation in ambulatory care. J Gen Intern Med. 2007;22(11):1523-6.
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psnet.ahrq.gov/issue/medication-errors-resulting-computer-entry-nonprescribers
January 02, 2017 - Study
Medication errors resulting from computer entry by nonprescribers.
Citation Text:
Santell JP, Kowiatek JG, Weber RJ, et al. Medication errors resulting from computer entry by nonprescribers. Am J Health Syst Pharm. 2009;66(9):843-53. doi:10.2146/ajhp080208.
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psnet.ahrq.gov/issue/drug-administration-errors-institution-individuals-intellectual-disability-observational
October 18, 2023 - Study
Drug administration errors in an institution for individuals with intellectual disability: an observational study.
Citation Text:
van den Bemt PMLA, Robertz R, de Jong AL, et al. Drug administration errors in an institution for individuals with intellectual disability: an observa…
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psnet.ahrq.gov/issue/patient-safety-primary-care-has-many-aspects-interview-study-primary-care-doctors-and-nurses
July 23, 2008 - Study
Patient safety in primary care has many aspects: an interview study in primary care doctors and nurses.
Citation Text:
Gaal S, van Laarhoven E, Wolters R, et al. Patient safety in primary care has many aspects: an interview study in primary care doctors and nurses. J Eval Clin Pr…
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psnet.ahrq.gov/issue/hospital-ward-incidents-through-eyes-nurses-thick-description-appeal-and-deadlock-incident
November 15, 2023 - Study
Hospital ward incidents through the eyes of nurses – a thick description on the appeal and deadlock of incident reporting systems.
Citation Text:
Tresfon J, van Winsen R, Brunsveld-Reinders AH, et al. Hospital ward incidents through the eyes of nurses - a thick description on the a…
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psnet.ahrq.gov/issue/preventing-medication-errors-quality-chasm-series
January 04, 2009 - Book/Report
Classic
Preventing Medication Errors: Quality Chasm Series.
Citation Text:
Preventing Medication Errors: Quality Chasm Series. Aspden P, Wolcott J, Bootman JL, et al, eds; Institute of Medicine, Committee on Identifying and Preventing Medication …
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psnet.ahrq.gov/issue/medication-administration-aged-care-facilities-mixed-methods-systematic-review-0
July 31, 2024 - Review
Medication administration in aged care facilities: a mixed-methods systematic review.
Citation Text:
Garratt S, Dowling A, Manias E. Medication administration in aged care facilities: a mixed‐methods systematic review. J Adv Nurs. 2025;81(2):621-640. doi:10.1111/jan.16318.
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psnet.ahrq.gov/issue/artificial-intelligence-health-care-accountability-and-safety
December 20, 2023 - Commentary
Classic
Artificial intelligence in health care: accountability and safety.
Citation Text:
Habli I, Lawton T, Porter Z. Artificial intelligence in health care: accountability and safety. Bull World Health Organ. 2020;98(4):251-256. doi:10.2471/blt.19.2…
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psnet.ahrq.gov/issue/instruments-patient-safety-assessment-scoping-review
October 12, 2022 - Review
Instruments for patient safety assessment: a scoping review.
Citation Text:
Nunes E, Sirtoli F, Lima E, et al. Instruments for patient safety assessment: a scoping review. Healthcare. 2024;12(20):2075. doi:10.3390/healthcare12202075.
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psnet.ahrq.gov/issue/machine-learning-medication-prescription-systematic-review
October 16, 2013 - Study
Machine learning in medication prescription: a systematic review.
Citation Text:
Iancu A, Leb I, Prokosch H-U, et al. Machine learning in medication prescription: a systematic review. Int J Med Inform. 2023;180:105241. doi:10.1016/j.ijmedinf.2023.105241.
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