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Call to action: addressing pediatric fall safety in ambulatory environments. | PSNet

psnet.ahrq.gov/issue/call-action-addressing-pediatric-fall-safety-ambulatory-environments

June 30, 2021 - Study Call to action: addressing pediatric fall safety in ambulatory environments. Citation Text: Benning S, Wolfe R, Banes M, et al. Call to action: addressing pediatric fall safety in ambulatory environments. J Pediatr Nurs. 2021;61:372-377. doi:10.1016/j.pedn.2021.09.012. Copy Citat…

Anesthesia machine as a cause of intraoperative "code red" in the labor and delivery suite. | PSNet

psnet.ahrq.gov/issue/anesthesia-machine-cause-intraoperative-code-red-labor-and-delivery-suite

August 16, 2023 - Commentary Anesthesia machine as a cause of intraoperative "code red" in the labor and delivery suite. Citation Text: Kuczkowski KM. Anesthesia machine as a cause of intraoperative "code red" in the labor and delivery suite. Arch Gynecol Obstet. 2008;278(5):477-8. doi:10.1007/s00404-008-…

Can a structured checklist prevent problems with laparoscopic equipment? | PSNet

psnet.ahrq.gov/issue/can-structured-checklist-prevent-problems-laparoscopic-equipment

August 10, 2016 - Study Can a structured checklist prevent problems with laparoscopic equipment? Citation Text: Verdaasdonk EGG, Stassen LPS, Hoffmann WF, et al. Can a structured checklist prevent problems with laparoscopic equipment? Surg Endosc. 2008;22(10):2238-43. doi:10.1007/s00464-008-0029-3. Co…

Predictors of completeness of patients' self-reported personal medication lists and discrepancies with clinic medication lists. | PSNet

psnet.ahrq.gov/issue/predictors-completeness-patients-self-reported-personal-medication-lists-and-discrepancies

October 19, 2022 - Study Predictors of completeness of patients' self-reported personal medication lists and discrepancies with clinic medication lists. Citation Text: Lee KP, Nishimura K, Ngu B, et al. Predictors of completeness of patients' self-reported personal medication lists and discrepancies with…

Cost-effectiveness of an electronic medication ordering and administration system in reducing adverse drug events. | PSNet

psnet.ahrq.gov/issue/cost-effectiveness-electronic-medication-ordering-and-administration-system-reducing-adverse

June 01, 2012 - Study Cost-effectiveness of an electronic medication ordering and administration system in reducing adverse drug events. Citation Text: Wu RC, Laporte A, Ungar WJ. Cost-effectiveness of an electronic medication ordering and administration system in reducing adverse drug events. J Eval …

Extraneous tissue a potential source for diagnostic error in surgical pathology. | PSNet

psnet.ahrq.gov/issue/extraneous-tissue-potential-source-diagnostic-error-surgical-pathology

October 27, 2010 - Study Extraneous tissue a potential source for diagnostic error in surgical pathology. Citation Text: Layfield LJ, Witt BL, Metzger KG, et al. Extraneous tissue: a potential source for diagnostic error in surgical pathology. Am J Clin Pathol. 2011;136(5):767-72. doi:10.1309/AJCP4FFSBPHA…

Pain as the neglected patient safety concern: five years on. | PSNet

psnet.ahrq.gov/issue/pain-neglected-patient-safety-concern-five-years

July 31, 2019 - Commentary Pain as the neglected patient safety concern: five years on. Citation Text: Twycross A, Forgeron P, Chorne J, et al. Pain as the neglected patient safety concern: Five years on. J Child Health Care. 2016;20(4):537-541. doi:10.1177/1367493516643422. Copy Citation Format: …

AHRQ PSNet Annual Webinar: Evidence on Advancing Rapid Response Systems and Opioid Stewardship. | PSNet

psnet.ahrq.gov/issue/ahrq-psnet-annual-webinar-evidence-advancing-rapid-response-systems-and-opioid-stewardship

December 10, 2024 - Webinar AHRQ PSNet Annual Webinar: Evidence on Advancing Rapid Response Systems and Opioid Stewardship. Citation Text: Agency for Healthcare Quality and Research. AHRQ PSNet Annual Webinar: Evidence on Advancing Rapid Response Systems and Opioid Stewardship. February 10, 2025, 1:00pm-2:0…

Development of the ICU safety reporting system. | PSNet

psnet.ahrq.gov/issue/development-icu-safety-reporting-system

May 27, 2011 - Study Development of the ICU safety reporting system. Citation Text: Development of the ICU safety reporting system. Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1(1):23-32. Copy Citation Save Save to your library Print Download PD…

Optimizing Pediatric Patient Safety in the Emergency Care Setting. | PSNet

psnet.ahrq.gov/issue/optimizing-pediatric-patient-safety-emergency-care-setting

March 15, 2023 - Organizational Policy/Guidelines Optimizing Pediatric Patient Safety in the Emergency Care Setting. Citation Text: Joseph MM, Mahajan P, Snow SK, et al. Optimizing Pediatric Patient Safety in the Emergency Care Setting. Pediatrics. 2022;150(5):e2022059673. doi:10.1542/peds.2022-059673. …

The need for closed-loop systems for management of abnormal test results. | PSNet

psnet.ahrq.gov/issue/need-closed-loop-systems-management-abnormal-test-results

May 20, 2019 - Study The need for closed-loop systems for management of abnormal test results. Citation Text: Zuccotti G, Samal L, Maloney FL, et al. The Need for Closed-Loop Systems for Management of Abnormal Test Results. Ann Intern Med. 2018;168(11):820-821. doi:10.7326/M17-2425. Copy Citation …

Americans' Experiences With Medical Errors and Views on Patient Safety. | PSNet

psnet.ahrq.gov/issue/americans-experiences-medical-errors-and-views-patient-safety

January 06, 2015 - Book/Report Classic Americans' Experiences With Medical Errors and Views on Patient Safety. Citation Text: Americans' Experiences With Medical Errors and Views on Patient Safety. Chicago, IL: NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute;…

Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration. | PSNet

psnet.ahrq.gov/issue/patient-misidentification-laboratory-medicine-qualitative-analysis-227-root-cause-analysis

August 28, 2024 - Study Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration. Citation Text: Dunn EJ, Moga PJ. Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis …

Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome. | PSNet

psnet.ahrq.gov/issue/doing-right-things-and-doing-them-right-way-association-between-hospital-guideline-adherence

February 03, 2011 - Study Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome. Citation Text: Mehta RH, Chen AY, Alexander KP, et al. Doing the right things and doing them the right way…

Hospital ward incidents through the eyes of nurses – a thick description on the appeal and deadlock of incident reporting systems. | PSNet

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…

Improving medication-related safety for residents in nursing homes: a qualitative study. | PSNet

psnet.ahrq.gov/issue/improving-medication-related-safety-residents-nursing-homes-qualitative-study

March 24, 2019 - Study Improving medication-related safety for residents in nursing homes: a qualitative study. Citation Text: Shieu B, Lee Y-W, Epps F, et al. Improving medication-related safety for residents in nursing homes: a qualitative study. J Gerontol Nurs. 2025;51(3):38-43. doi:10.3928/00989134-…

Standardization in patient safety: the WHO High 5s project. | PSNet

psnet.ahrq.gov/issue/standardization-patient-safety-who-high-5s-project

January 12, 2022 - Commentary Standardization in patient safety: the WHO High 5s project. Citation Text: Leotsakos A, Zheng H, Croteau R, et al. Standardization in patient safety: the WHO High 5s project. Int J Qual Health Care. 2014;26(2):109-16. doi:10.1093/intqhc/mzu010. Copy Citation Format: …

Debriefing in the emergency department after clinical events: a practical guide. | PSNet

psnet.ahrq.gov/issue/debriefing-emergency-department-after-clinical-events-practical-guide

November 16, 2022 - Commentary Debriefing in the emergency department after clinical events: a practical guide. Citation Text: Kessler DO, Cheng A, Mullan PC. Debriefing in the Emergency Department After Clinical Events: A Practical Guide. Ann Emerg Med. 2015;65(6):690-698. doi:10.1016/j.annemergmed.2014.10…

The relationship between resident burnout and safety-related and acceptability-related quality of healthcare: a systematic literature review. | PSNet

psnet.ahrq.gov/issue/relationship-between-resident-burnout-and-safety-related-and-acceptability-related-quality

October 26, 2010 - Review The relationship between resident burnout and safety-related and acceptability-related quality of healthcare: a systematic literature review. Citation Text: Dewa CS, Loong D, Bonato S, et al. The relationship between resident burnout and safety-related and acceptability-related qu…

Using Lean "automation with a human touch" to improve medication safety: a step closer to the "perfect dose." | PSNet

psnet.ahrq.gov/issue/using-lean-automation-human-touch-improve-medication-safety-step-closer-perfect-dose

September 16, 2015 - Study Using Lean "automation with a human touch" to improve medication safety: a step closer to the "perfect dose." Citation Text: Ching JM, Williams BL, Idemoto LM, et al. Using lean "automation with a human touch" to improve medication safety: a step closer to the "perfect dose". Jt Co…

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