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psnet.ahrq.gov/node/43481/psn-pdf
December 23, 2016 - Managing risk during transition to new ISO tubing
connector standards.
December 23, 2016
Sentinel Event Alert. August 20, 2014;(53):1-6.
https://psnet.ahrq.gov/issue/managing-risk-during-transition-new-iso-tubing-connector-standards
The Joint Commission issues sentinel event alerts in response to significant emerg…
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psnet.ahrq.gov/node/41465/psn-pdf
January 31, 2013 - Emergency department discharge prescription
interventions by emergency medicine pharmacists.
January 31, 2013
Cesarz JL, Steffenhagen AL, Svenson J, et al. Emergency department discharge prescription interventions
by emergency medicine pharmacists. Ann Emerg Med. 2013;61(2):209-214.e1.
doi:10.1016/j.annemergmed.20…
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psnet.ahrq.gov/node/73604/psn-pdf
August 18, 2021 - The effect of providing staff training and enhanced
support to care homes on care processes, safety climate
and avoidable harms: evaluation of a care home quality
improvement programme in England.
August 18, 2021
Damery S, Flanagan S, Jones J, et al. The effect of providing staff training and enhanced support to c…
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psnet.ahrq.gov/issue/marylanddc-patient-safety-coalition
September 28, 2023 - Multi-use Website
Maryland/DC Patient Safety Coalition.
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March 17, 2011
The Maryland Patient Safety Center facilitates the study …
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psnet.ahrq.gov/node/60250/psn-pdf
April 22, 2020 - Implementation of a comprehensive unit-based safety
program to reduce surgical site infections in cesarean
delivery.
April 22, 2020
Dieplinger B, Egger M, Jezek C, et al. Implementation of a comprehensive unit-based safety program to
reduce surgical site infections in cesarean delivery. Am J Infect Control. 2020;4…
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psnet.ahrq.gov/node/36700/psn-pdf
July 20, 2011 - Adverse drug events resulting from patient errors in older
adults.
July 20, 2011
Field TS, Mazor KM, Briesacher BA, et al. Adverse Drug Events Resulting from Patient Errors in Older
Adults. J Am Geriatr Soc. 2007;55(2):271-276. doi:10.1111/j.1532-5415.2007.01047.x.
https://psnet.ahrq.gov/issue/adverse-drug-events-…
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psnet.ahrq.gov/node/849128/psn-pdf
May 17, 2023 - Is primary care a patient-safe setting? Prevalence,
severity, nature, and causes of adverse events: numerous
and mostly avoidable.
May 17, 2023
Garzón González G, Alonso Safont T, Zamarrón Fraile E, et al. Is primary care a patient-safe setting?
Prevalence, severity, nature, and causes of adverse events: numerous …
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psnet.ahrq.gov/node/34843/psn-pdf
March 02, 2011 - Hand hygiene among physicians: performance, beliefs,
and perceptions.
March 2, 2011
Pittet D, Simon A, Hugonnet S, et al. Hand hygiene among physicians: performance, beliefs, and
perceptions. Ann Intern Med. 2004;141(1):1-8.
https://psnet.ahrq.gov/issue/hand-hygiene-among-physicians-performance-beliefs-and-percept…
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psnet.ahrq.gov/node/50945/psn-pdf
February 26, 2020 - She hoped to shine a light on maternal mortality among
Native Americans. Instead, she became a statistic of it.
February 26, 2020
Chuck E, Assefa H. NBC News. February 8, 2020.
https://psnet.ahrq.gov/issue/she-hoped-shine-light-maternal-mortality-among-native-americans-instead-
she-became-statistic
Maternal morbi…
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psnet.ahrq.gov/node/836749/psn-pdf
March 16, 2022 - Comparison of a focused family cancer history
questionnaire to family history documentation in the
electronic medical record.
March 16, 2022
Clift K, Macklin-Mantia S, Barnhorst M, et al. Comparison of a focused family cancer history questionnaire
to family history documentation in the electronic medical record. J…
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psnet.ahrq.gov/node/72717/psn-pdf
February 10, 2021 - Hospital-acquired SARS-Cov-2 infections in patients:
inevitable conditions or medical malpractice?
February 10, 2021
Barranco R, Vallega Bernucci Du Tremoul L, Ventura F. Hospital-acquired SARS-Cov-2 infections in
patients: inevitable conditions or medical malpractice? Int J Environ Res Public Health. 2021;18(2):48…
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psnet.ahrq.gov/node/34063/psn-pdf
September 18, 2011 - Risk factors for retained instruments and sponges after
surgery.
September 18, 2011
Gawande AA, Studdert DM, Orav J, et al. Risk factors for retained instruments and sponges after surgery.
N Engl J Med. 2003;348(3):229-35.
https://psnet.ahrq.gov/issue/risk-factors-retained-instruments-and-sponges-after-surgery
Th…
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psnet.ahrq.gov/node/841143/psn-pdf
January 01, 2023 - Conceptual and practical challenges associated with
understanding patient safety within community-based
mental health services.
December 7, 2022
Averill P, Vincent CA, Reen G, et al. Conceptual and practical challenges associated with understanding
patient safety within community?based mental health services. Heal…
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digital.ahrq.gov/funding-mechanism/advancing-evidence-practice-through-shared-interoperable-clinical-decision-support
January 01, 2023 - Advancing Evidence into Practice through Shared, Interoperable Clinical Decision Support Resources (U18)
Shareable, Interoperable Clinical Decision Support for Older Adults: Advancing Fall Assessment and Prevention Patient-Centered Outcomes Research Findings into Diverse Primary Care Pr…
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psnet.ahrq.gov/node/39192/psn-pdf
February 02, 2011 - Contraindicated medication use in dialysis patients
undergoing percutaneous coronary intervention.
February 2, 2011
Tsai TT, Maddox TM, Roe MT, et al. Contraindicated medication use in dialysis patients undergoing
percutaneous coronary intervention. JAMA. 2009;302(22):2458-64. doi:10.1001/jama.2009.1800.
https://p…
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psnet.ahrq.gov/node/44949/psn-pdf
February 01, 2019 - Detecting and treating suicide ideation in all settings.
December 23, 2016
Detecting and treating suicide ideation in all settings. Sentinel event alert. 2016;(56):1-7.
https://psnet.ahrq.gov/issue/detecting-and-treating-suicide-ideation-all-settings
The Joint Commission publishes sentinel event alerts to emphasize…
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psnet.ahrq.gov/node/73855/psn-pdf
January 01, 2022 - The impact of coronavirus disease 2019 (COVID-19) on
healthcare-associated infections in 2020: a summary of
data reported to the National Healthcare Safety Network.
September 22, 2021
Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. The impact of coronavirus disease 2019 (COVID-
19) on healthcare-associated …
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psnet.ahrq.gov/node/844555/psn-pdf
February 15, 2023 - AHRQ-Funded Patient Safety Project Highlights:
Improving Healthcare Safety by Engaging Patients and
Families.
February 15, 2023
Rockville, MD: Agency for Healthcare Research and Quality; January 2023. AHRQ Pub. No.22(23)-0065-1.
https://psnet.ahrq.gov/issue/ahrq-funded-patient-safety-project-highlights-improving-h…
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psnet.ahrq.gov/issue/check-your-medicines-tips-taking-medicines-safely
September 04, 2018 - Government Resource
Check Your Medicines: Tips for Taking Medicines Safely.
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April 23, 2012
This 5-point checklist provides consu…
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psnet.ahrq.gov/node/37113/psn-pdf
March 24, 2011 - Mature rapid response system and potentially avoidable
cardiopulmonary arrests in hospital.
March 24, 2011
Galhotra S, DeVita MA, Simmons RL, et al. Mature rapid response system and potentially avoidable
cardiopulmonary arrests in hospital. Qual Saf Health Care. 2007;16(4):260-265.
https://psnet.ahrq.gov/issue/mat…