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psnet.ahrq.gov/node/48155/psn-pdf
August 07, 2019 - How to prevent or reduce prescribing errors: an evidence
brief for policy authors.
August 7, 2019
de Araújo BC, de Melo RC, de Bortoli MC, et al. How to prevent or reduce prescribing errors: an evidence
brief for policy authors. Front Pharmacol. 2019;10:439. doi:10.3389/fphar.2019.00439.
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August 03, 2011 - Effectiveness and cost of a transitional care program for
heart failure: a prospective study with concurrent
controls.
August 3, 2011
Stauffer BD, Fullerton C, Fleming N, et al. Effectiveness and cost of a transitional care program for heart
failure: a prospective study with concurrent controls. Arch Intern Med. 2…
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June 04, 2014 - Back to basics: preventing surgical site infections.
June 4, 2014
Spruce L. Back to basics: preventing surgical site infections. AORN J. 2014;99(5):600-8; quiz 609-11.
doi:10.1016/j.aorn.2014.02.002.
https://psnet.ahrq.gov/issue/back-basics-preventing-surgical-site-infections
Surgical site infections are a common …
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psnet.ahrq.gov/node/39479/psn-pdf
January 20, 2011 - A comparative analysis of incident reporting lag times in
academic medical centres in Japan and the USA.
January 20, 2011
Regenbogen SE, Hirose M, Imanaka Y, et al. A comparative analysis of incident reporting lag times in
academic medical centres in Japan and the USA. Qual Saf Health Care. 2010;19(6):e10.
doi:10.…
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psnet.ahrq.gov/node/60904/psn-pdf
September 09, 2020 - Two pandemics, same story: the potentially dangerous
overuse of antibiotics and 'the road to medical hell'.
September 9, 2020
Fauber J, Chen D. Milwaukee Journal Sentinel. August 31, 2020.
https://psnet.ahrq.gov/issue/two-pandemics-same-story-potentially-dangerous-overuse-antibiotics-and-
road-medical-hell
Antibi…
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psnet.ahrq.gov/node/50656/psn-pdf
November 13, 2019 - Whistleblowing over patient safety and care quality: a
review of the literature.
November 13, 2019
Blenkinsopp J, Snowden N, Mannion R, et al. Whistleblowing over patient safety and care quality: a review
of the literature. J Health Org Manag. 2019;33(6):737-756. doi:10.1108/JHOM-12-2018-0363.
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October 29, 2017 - Public reporting of surgical outcomes: surgeons,
hospitals, or both?
October 29, 2017
Jha AK. Public Reporting of Surgical Outcomes: Surgeons, Hospitals, or Both? JAMA. 2017;318(15):1429-
1430. doi:10.1001/jama.2017.13815.
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…
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psnet.ahrq.gov/node/44072/psn-pdf
August 02, 2015 - The rise of the medical scribe industry: implications for
the advancement of electronic health records.
August 2, 2015
Gellert GA, Ramirez R, Webster L. The rise of the medical scribe industry: implications for the
advancement of electronic health records. JAMA. 2015;313(13):1315-1316. doi:10.1001/jama.2014.17128.
…
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psnet.ahrq.gov/node/36017/psn-pdf
June 14, 2006 - Medical errors and quality of care: from control to
commitment.
June 14, 2006
Khatri N, Baveja A, Boren SA, et al. Medical Errors and Quality of Care: From Control to Commitment.
California Manage Review. 2006;48(3):115-141. doi:10.2307/41166353.
https://psnet.ahrq.gov/issue/medical-errors-and-quality-care-control…
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psnet.ahrq.gov/node/35023/psn-pdf
March 04, 2011 - Building a framework for trust: critical event analysis of
deaths in surgical care.
March 4, 2011
Thompson A, Stonebridge PA. Building a framework for trust: critical event analysis of deaths in surgical
care. BMJ. 2005;330(7500):1139-42.
https://psnet.ahrq.gov/issue/building-framework-trust-critical-event-analysi…
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June 24, 2010 - Patient safety problems in adolescent medical care.
June 24, 2010
Woods D, Holl JL, Klein JD, et al. Patient safety problems in adolescent medical care. J Adolesc Health.
2006;38(1):5-12.
https://psnet.ahrq.gov/issue/patient-safety-problems-adolescent-medical-care
Using data from the Colorado and Utah Medical Prac…
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psnet.ahrq.gov/node/43797/psn-pdf
January 07, 2015 - Building a community engagement approach for patient
safety improvement.
January 7, 2015
Gooden R, Syed SB, Rutter P, et al. Building a community engagement approach for patient safety
improvement. Community Dev J. 2013;49(4). doi:10.1093/cdj/bst044.
https://psnet.ahrq.gov/issue/building-community-engagement-appro…
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psnet.ahrq.gov/node/43835/psn-pdf
February 11, 2015 - Doctors' experiences of adverse events in secondary
care: the professional and personal impact.
February 11, 2015
Harrison R, Lawton R, Stewart K. Doctors' experiences of adverse events in secondary care: the
professional and personal impact. Clin Med (Lond). 2014;14(6):585-90. doi:10.7861/clinmedicine.14-6-585.
h…
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psnet.ahrq.gov/node/42915/psn-pdf
January 01, 2016 - Reducing Avoidable Readmissions Effectively campaign:
a statewide collaborative.
February 5, 2014
McCoy KA, Bear-Pfaffendorf K, Foreman JK, et al. Reducing Avoidable Hospital Readmissions Effectively:
A Statewide Campaign. Joint Comm J Qual Patient Saf. 2016;40(5):198-204, AP2. doi:10.1016/s1553-
7250(14)40026-6.
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December 16, 2020 - Hidden medication loss when using a primary
administration set for small-volume intermittent infusions.
December 16, 2020
ISMP Medication Safety Alert! Acute care edition. December 3, 2020;25(24).
https://psnet.ahrq.gov/issue/hidden-medication-loss-when-using-primary-administration-set-small-volume-
intermittent
…
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September 20, 2023 - How Columbia ignored women, undermined prosecutors
and protected a predator for more than 20 years.
September 20, 2023
Fortis B, Bell L. Pro Publica. September 12, 2023.
https://psnet.ahrq.gov/issue/how-columbia-ignored-women-undermined-prosecutors-and-protected-
predator-more-20-years
Sexual abuse of a patient i…
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psnet.ahrq.gov/node/47355/psn-pdf
September 05, 2018 - Preventing medication errors in the information age.
September 5, 2018
Godshall M, Riehl M. Preventing medication errors in the information age. Nursing (Brux). 2018;48(9):56-
58. doi:10.1097/01.NURSE.0000544230.51598.38.
https://psnet.ahrq.gov/issue/preventing-medication-errors-information-age
Failure to consider…
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psnet.ahrq.gov/node/45073/psn-pdf
May 11, 2016 - Promoting patient safety: results of a TeamSTEPPS
initiative.
May 11, 2016
Gaston T, Short N, Ralyea C, et al. Promoting patient safety: results of a TeamSTEPPS initiative. J Nurs
Adm. 2016;46(4):201-207. doi:10.1097/nna.0000000000000333.
https://psnet.ahrq.gov/issue/promoting-patient-safety-results-teamstepps-ini…
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psnet.ahrq.gov/node/43412/psn-pdf
May 28, 2015 - An observational study of how patients are identified
before medication administrations in medical and surgical
wards.
May 28, 2015
Härkänen M, Kervinen M, Ahonen J, et al. An observational study of how patients are identified before
medication administrations in medical and surgical wards. Nurs Health Sci. 2015;1…
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psnet.ahrq.gov/node/34780/psn-pdf
March 28, 2005 - Disseminating innovations in health care.
March 28, 2005
Berwick DM. Disseminating Innovations in Health Care. JAMA. 2003;289(15):1969-1975.
doi:10.1001/jama.289.15.1969.
https://psnet.ahrq.gov/issue/disseminating-innovations-health-care
This commentary and review discusses the ability to adopt growing numbers of …