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psnet.ahrq.gov/node/37430/psn-pdf
February 01, 2011 - Nonpayment for harms resulting from medical care:
catheter-associated urinary tract infections.
February 1, 2011
Wald HL, Kramer AM. Nonpayment for harms resulting from medical care: catheter-associated urinary tract
infections. JAMA. 2007;298(23):2782-4. doi:10.1001/jama.298.23.2782.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/38332/psn-pdf
January 14, 2009 - Verifying patient identity and site of surgery: improving
compliance with protocol by audit and feedback.
January 14, 2009
Garnerin P, Arès M, Huchet A, et al. Verifying patient identity and site of surgery: improving compliance
with protocol by audit and feedback. Qual Saf Health Care. 2008;17(6):454-8.
doi:10.11…
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psnet.ahrq.gov/node/37545/psn-pdf
February 20, 2008 - Iatrogenic events in admitted neonates: a prospective
cohort study.
February 20, 2008
Ligi I, Arnaud F, Jouve E, et al. Iatrogenic events in admitted neonates: a prospective cohort study. Lancet.
2008;371(9610):404-10. doi:10.1016/S0140-6736(08)60204-4.
https://psnet.ahrq.gov/issue/iatrogenic-events-admitted-neona…
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psnet.ahrq.gov/node/836809/psn-pdf
March 30, 2022 - Pharmacist transition-of-care services improve patient
satisfaction and decrease hospital readmissions.
March 30, 2022
March KL, Peters MJ, Finch CK, et al. J Pharm Pract. 2022;35(1):86-93.
https://psnet.ahrq.gov/issue/pharmacist-transition-care-services-improve-patient-satisfaction-and-decrease-
hospital
Tr…
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psnet.ahrq.gov/node/45455/psn-pdf
June 29, 2017 - JAMA professionalism: disclosure of medical error.
June 29, 2017
Levinson W, Yeung J, Ginsburg S. Disclosure of Medical Error. JAMA. 2016;316(7):764-5.
doi:10.1001/jama.2016.9136.
https://psnet.ahrq.gov/issue/jama-professionalism-disclosure-medical-error
Disclosing medical errors to patients is essential for maint…
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psnet.ahrq.gov/node/36005/psn-pdf
March 28, 2011 - Active surveillance using electronic triggers to detect
adverse events in hospitalized patients.
March 28, 2011
Szekendi MK, Sullivan C, Bobb A, et al. Active surveillance using electronic triggers to detect adverse
events in hospitalized patients. Qual Saf Health Care. 2006;15(3):184-90.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/47865/psn-pdf
April 17, 2019 - The effect of a residential care pharmacist on medication
administration practices in aged care: a controlled trial.
April 17, 2019
McDerby N, Kosari S, Bail K, et al. The effect of a residential care pharmacist on medication administration
practices in aged care: A controlled trial. J Clin Pharm Ther. 2019;44(4):5…
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psnet.ahrq.gov/node/844785/psn-pdf
September 11, 2019 - Information flow during pediatric trauma care transitions:
things falling through the cracks.
September 11, 2019
Hoonakker PLT, Wooldridge AR, Hose B-Z, et al. Information flow during pediatric trauma care transitions:
things falling through the cracks. Intern Emerg Med. 2019;14(5):797-805. doi:10.1007/s11739-019-0…
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psnet.ahrq.gov/node/866955/psn-pdf
October 16, 2024 - Adverse diagnostic events in hospitalised patients: a
single-centre, retrospective cohort study.
October 16, 2024
Dalal AK, Plombon S, Konieczny K, et al. Adverse diagnostic events in hospitalised patients: a single-
centre, retrospective cohort study. BMJ Qual Saf. 2024;Epub Oct 1. doi:10.1136/bmjqs-2024-017183.
…
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psnet.ahrq.gov/node/866581/psn-pdf
August 28, 2024 - Diagnostic errors in obstetric morbidity and mortality:
methods for and challenges in seeking diagnostic
excellence.
August 28, 2024
Krenitsky NM, Perez-Urbano I, Goffman D. Diagnostic errors in obstetric morbidity and mortality: methods
for and challenges in seeking diagnostic excellence. J Clin Med. 2024;13(14):…
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psnet.ahrq.gov/node/39088/psn-pdf
September 01, 2015 - Laboratory session to improve first-year pharmacy
students' knowledge and confidence concerning the
prevention of medication errors.
September 1, 2015
Kiersma ME, Darbishire PL, Plake KS, et al. Laboratory session to improve first-year pharmacy students'
knowledge and confidence concerning the prevention of medica…
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psnet.ahrq.gov/node/35909/psn-pdf
October 07, 2008 - Committed to Safety: Ten Case Studies on Reducing
Harm to Patients.
October 7, 2008
McCarthy D, Blumenthal D. New York, NY: Commonwealth Fund; 2006.
https://psnet.ahrq.gov/issue/committed-safety-ten-case-studies-reducing-harm-patients
This report presents ten case studies to illustrate interventions that address p…
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psnet.ahrq.gov/node/74271/psn-pdf
January 19, 2022 - Improving shared situation awareness for high-risk
therapies in hospitalized children.
January 19, 2022
Sosa T, Mayer B, Chakkalakkal B, et al. Improving shared situation awareness for high-risk therapies in
hospitalized children. Hosp Pediatr. 2022;12(1):37-46. doi:10.1542/hpeds.2021-006193.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/47836/psn-pdf
May 29, 2019 - FDA to end program that hid millions of reports on faulty
medical devices.
May 29, 2019
Jewett C. Kaiser Health News. May 3, 2019.
https://psnet.ahrq.gov/issue/fda-end-program-hid-millions-reports-faulty-medical-devices
Transparency has been heralded as a cornerstone to improvement in health care. This news articl…
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psnet.ahrq.gov/node/47840/psn-pdf
July 31, 2019 - Development and performance evaluation of the
Medicines Optimisation Assessment Tool (MOAT): a
prognostic model to target hospital pharmacists' input to
prevent medication-related problems.
July 31, 2019
Geeson C, Wei L, Franklin BD. Development and performance evaluation of the Medicines Optimisation
Assessment …
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psnet.ahrq.gov/node/47574/psn-pdf
November 21, 2018 - The architecture of safety: an emerging priority for
improving patient safety.
November 21, 2018
Joseph A, Henriksen K, Malone E. The Architecture Of Safety: An Emerging Priority For Improving Patient
Safety. Health Aff (Millwood). 2018;37(11):1884-1891. doi:10.1377/hlthaff.2018.0643.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/47402/psn-pdf
March 13, 2019 - In-hospital sequelae of injurious falls in 24
medical/surgical units in four hospitals in the United
States.
March 13, 2019
Hill A-M, Jacques A, Chandler M, et al. In-Hospital Sequelae of Injurious Falls in 24 Medical/Surgical Units
in Four Hospitals in the United States. Jt Comm J Qual Patient Saf. 2019;45(2):91-…
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psnet.ahrq.gov/node/74870/psn-pdf
April 11, 2022 - Proposed 2022 CDC clinical practice guideline for
prescribing opioids. A notice by the Centers for Disease
Control and Prevention.
February 23, 2022
Fed Register. February 10, 2022;87: 7838-7840.
https://psnet.ahrq.gov/issue/proposed-2022-cdc-clinical-practice-guideline-prescribing-opioids-notice-
centers-disease…
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digital.ahrq.gov/ahrq-funded-projects/patient-centered-outcomes-research-clinical-decision-support-cds-connect/citation/aspirin
January 01, 2023 - Implementation guide: USPSTF aspirin therapy for the primary prevention of cardiovascular disease and colorectal cancer.
Citation
Ricciardelli P, Sebastian S, Teich, J. Implementation guide: USPSTF aspirin therapy for the primary prevention of cardiovascular disease and colorectal cancer. Prepared un…
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digital.ahrq.gov/ahrq-funded-projects/patient-centered-outcomes-research-clinical-decision-support-cds-connect/citation/statin
January 01, 2023 - Implementation guide: statin therapy for the prevention and treatment of cardiovascular disease (CVD) electronic Clinical Quality Measure (eCQM).
Citation
Ricciardelli P, Sebastian S, Teich, J. Implementation guide: statin therapy for the prevention and treatment of cardiovascular disease (CVD) electr…