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psnet.ahrq.gov/node/47478/psn-pdf
January 16, 2019 - Prospective daily review of discharge medications by
pharmacists: effects on measures of safety and
efficiency.
January 16, 2019
Craynon R, Hager DR, Reed M, et al. Prospective daily review of discharge medications by pharmacists:
Effects on measures of safety and efficiency. Am J Health Syst Pharm. 2018;75(19):14…
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psnet.ahrq.gov/node/837736/psn-pdf
July 27, 2022 - Body mass index category and adverse events in
hospitalized children.
July 27, 2022
Halvorson EE, Thurtle DP, Easter A, et al. Body mass index category and adverse events in hospitalized
children. Acad Pediatr. 2022;22(5):747-753. doi:10.1016/j.acap.2021.09.004.
https://psnet.ahrq.gov/issue/body-mass-index-categor…
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psnet.ahrq.gov/node/845350/psn-pdf
March 01, 2023 - Implementing human factors in anaesthesia: guidance for
clinicians, departments and hospitals: Guidelines from
the Difficult Airway Society and the Association of
Anaesthetists.
March 1, 2023
Kelly FE, Frerk C, Bailey CR, et al. Implementing human factors in anaesthesia: guidance for clinicians,
departments and h…
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psnet.ahrq.gov/node/73984/psn-pdf
October 20, 2021 - Analyzing diagnostic errors in the acute setting: a
process-driven approach.
October 20, 2021
Griffin JA, Carr K, Bersani K, et al. Analyzing diagnostic errors in the acute setting: a process-driven
approach. Diagnosis (Berl). 2022;9(1):77-88. doi:10.1515/dx-2021-0033.
https://psnet.ahrq.gov/issue/analyzing-diagno…
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psnet.ahrq.gov/node/35207/psn-pdf
December 19, 2009 - Patient safety concerns arising from test results that
return after hospital discharge.
December 19, 2009
Roy CL, Poon EG, Karson A, et al. Patient safety concerns arising from test results that return after hospital
discharge. Ann Intern Med. 2005;143(2):121-128.
https://psnet.ahrq.gov/issue/patient-safety-concer…
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psnet.ahrq.gov/node/47186/psn-pdf
October 24, 2018 - Quality, Value, and Patient Safety in Orthopedic Surgery.
October 24, 2018
Azar FM, ed. Orthop Clin North Am. 2018;49(4):A1-A8,389-552.
https://psnet.ahrq.gov/issue/quality-value-and-patient-safety-orthopedic-surgery
Quality and value have intersecting influence on the safety of health care. Articles in this specia…
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psnet.ahrq.gov/node/837694/psn-pdf
July 20, 2022 - Implementing root cause analysis and action: integrating
human factors to create strong interventions and reduce
risk of patient harm.
July 20, 2022
Wolf L, Gorman K, Clark J, et al. Implementing root cause analysis and action: integrating human factors to
create strong interventions and reduce risk of patient har…
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psnet.ahrq.gov/node/844987/psn-pdf
February 22, 2023 - Examining medication ordering errors using AHRQ
Network of Patient Safety Databases.
February 22, 2023
Grauer A, Rosen A, Applebaum JR, et al. Examining medication ordering errors using AHRQ network of
patient safety databases. J Am Med Inform Assoc. 2023;30(5):838-845. doi:10.1093/jamia/ocad007.
https://psnet.ahr…
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psnet.ahrq.gov/node/854389/psn-pdf
October 11, 2023 - Alliance for Innovation on Maternal Health: Consensus
Bundle on Sepsis in Obstetric Care.
October 11, 2023
Bauer ME, Albright C, Prabhu M, et al. Alliance for Innovation on Maternal Health: Consensus Bundle on
Sepsis in Obstetric Care. Obstet Gynecol. 2023;142(3):481-492. doi:10.1097/aog.0000000000005304.
https://…
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psnet.ahrq.gov/node/50918/psn-pdf
February 19, 2020 - Finding dental harm to patients through electronic health
record-based triggers.
February 19, 2020
Walji MF, Yansane A, Hebballi NB, et al. Finding dental harm to patients through electronic health record-
based triggers . JDR Clin Trans Res. 2020;5(3):271-277. doi:10.1177/2380084419892550.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/46920/psn-pdf
August 08, 2018 - Identification and characterization of failures in infectious
agent transmission precaution practices in hospitals: a
qualitative study.
August 8, 2018
Krein SL, Mayer J, Harrod M, et al. Identification and Characterization of Failures in Infectious Agent
Transmission Precaution Practices in Hospitals: A Qualitati…
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psnet.ahrq.gov/node/45815/psn-pdf
January 25, 2017 - Handoffs: transitions of care for children in the
emergency department.
January 25, 2017
American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of
Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association
Pediatric Committee. Pediatrics. 2016;138:…
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psnet.ahrq.gov/node/837671/psn-pdf
July 13, 2022 - Long-term care healthcare-associated infections in 2021:
an analysis of 17,971 reports.
July 13, 2022
Kepner S, Adkins JA, Jones RM. Long-term care healthcare-associated infections in 2021: an analysis of
17,971 reports. Patient Saf. 2022;4(2):6-17. doi:10.33940/data/2022.6.1.
https://psnet.ahrq.gov/issue/long-ter…
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psnet.ahrq.gov/node/849331/psn-pdf
May 24, 2023 - Long-term care healthcare-associated infections in 2022:
an analysis of 20,216 reports.
May 24, 2023
Kepner S, Bingman C, Jones RM. Long-term care healthcare-associated iInfections in 2022: an analysis of
20,216 reports. Patient Saf. 2023;5(2):20-31. doi:10.33940/001c.74494.
https://psnet.ahrq.gov/issue/long-term-…
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psnet.ahrq.gov/node/34784/psn-pdf
June 24, 2015 - The potential for improved teamwork to reduce medical
errors in the emergency department.
June 24, 2015
Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in
the emergency department. Ann Emerg Med. 2005;34(3):373-383. doi:10.1016/s0196-0644(99)70134-4.
https://ps…
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psnet.ahrq.gov/node/44898/psn-pdf
November 23, 2016 - Types and patterns of safety concerns in home care:
client and family caregiver perspectives.
November 23, 2016
Tong CE, Sims-Gould J, Martin-Matthews A. Types and patterns of safety concerns in home care: client
and family caregiver perspectives. Int J Qual Health Care. 2016;28(2):214-220.
doi:10.1093/intqhc/mzw0…
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psnet.ahrq.gov/node/74005/psn-pdf
October 27, 2021 - The postpartum hemorrhage patient safety bundle
implementation at a single institution: successes,
failures, and lessons learned,
October 27, 2021
Duzyj CM, Boyle C, Mahoney K, et al. The postpartum hemorrhage patient safety bundle implementation at
a single institution: successes, failures, and lessons learned. A…
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psnet.ahrq.gov/node/44344/psn-pdf
July 22, 2015 - Making healthcare safer by understanding, designing and
buying better IT.
July 22, 2015
Thimbleby H, Lewis A, Williams J. Making healthcare safer by understanding, designing and buying better
IT. Clin Med (Lond). 2015;15(3):258-62. doi:10.7861/clinmedicine.15-3-258.
https://psnet.ahrq.gov/issue/making-healthcare-s…
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psnet.ahrq.gov/node/47832/psn-pdf
February 27, 2019 - Another round of the blame game: a paralyzing criminal
indictment that recklessly "overrides" just culture.
February 27, 2019
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
https://psnet.ahrq.gov/issue/another-round-blame-game-paralyzing-criminal-indictment-recklessly-
overrides-just-cultu…
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psnet.ahrq.gov/node/851201/psn-pdf
July 05, 2023 - ‘I felt like I was dying’: how women with postpartum
depression fall through the cracks of U.S. health care.
July 5, 2023
Gammon K. STAT. June 26, 2023.
https://psnet.ahrq.gov/issue/i-felt-i-was-dying-how-women-postpartum-depression-fall-through-cracks-us-
health-care
The maternal mental health crisis results in …