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psnet.ahrq.gov/node/852275/psn-pdf
January 01, 2024 - Improving emergency medicine clinician awareness of
prehospital-administered medications.
August 9, 2023
Kamta J, Fregoso B, Lee A, et al. Improving emergency medicine clinician awareness of prehospital-
administered medications. Prehosp Emerg Care. 2024;28(3):506-512.
doi:10.1080/10903127.2023.2238815.
https://p…
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psnet.ahrq.gov/node/74239/psn-pdf
January 12, 2022 - Evaluation of clinical practice guidelines on fall
prevention and management for older adults: a
systematic review.
January 12, 2022
Montero-Odasso MM, Kamkar N, Pieruccini-Faria F, et al. Evaluation of clinical practice guidelines on fall
prevention and management for older adults: a systematic review. JAMA Netw …
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psnet.ahrq.gov/node/838250/psn-pdf
October 06, 2022 - The impact of electronic communication of medication
discontinuation (CancelRx) on medication safety: a pilot
study.
October 6, 2022
Pitts S, Yang Y, Woodroof T, et al. The impact of electronic communication of medication discontinuation
(CancelRx) on medication safety: a pilot study. J Patient Saf. 2022;18(6):e93…
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psnet.ahrq.gov/issue/patient-stories
March 27, 2024 - Multi-use Website
Patient Stories.
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March 6, 2013
This Web site hosts documentary accounts of medical errors to encourage clinici…
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psnet.ahrq.gov/node/45199/psn-pdf
June 15, 2016 - Towards safer transitions: a curriculum to teach and
assess hospital-to-hospice handoffs.
June 15, 2016
Darrah NJ, O'Connor NR. Toward Safer Transitions: A Curriculum to Teach and Assess Hospital-to-
Hospice Handoffs. J Pain Symptom Manage. 2016;51(6):959-962.e2.
doi:10.1016/j.jpainsymman.2016.01.012.
https://psn…
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psnet.ahrq.gov/node/35309/psn-pdf
January 02, 2017 - Advising patients about patient safety: current initiatives
risk shifting responsibility.
January 2, 2017
Entwistle V, Mello MM, Brennan TA. Advising Patients About Patient Safety: Current Initiatives Risk
Shifting Responsibility. Jt Comm J Qual Patient Saf. 2005;31(9):483-494. doi:10.1016/s1553-
7250(05)31063-4.
…
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psnet.ahrq.gov/node/46886/psn-pdf
August 01, 2018 - Support strategies for health care professionals who are
second victims.
August 1, 2018
Hauk L. Support strategies for health care professionals who are second victims. AORN J. 2018;107(6):P7-
P9. doi:10.1002/aorn.12291.
https://psnet.ahrq.gov/issue/support-strategies-health-care-professionals-who-are-second-victi…
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psnet.ahrq.gov/issue/safe-care-patient-safety-education-program
May 13, 2021 - Image/Poster
SAFE CARE Patient Safety Education Program.
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October 31, 2012
This Web site provides patient safety resources, inclu…
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psnet.ahrq.gov/node/862617/psn-pdf
February 14, 2024 - Risks to Medication Delivery Using Ambulatory Infusion
Pumps – Design and Usability in Inpatient Settings.
February 14, 2024
Dorset, UK: Health Services Safety Investigations Body; November 2023.
https://psnet.ahrq.gov/issue/risks-medication-delivery-using-ambulatory-infusion-pumps-design-and-
usability-inpatient
…
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psnet.ahrq.gov/node/60045/psn-pdf
March 18, 2020 - Making Healthcare Safer III.
March 18, 2020
Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March
2020. AHRQ Publication No. 20-0029-EF.
https://psnet.ahrq.gov/issue/making-healthcare-safer-iii
This newly issued follow up to the seminal AHRQ Making Health Care Safer rep…
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psnet.ahrq.gov/node/857445/psn-pdf
January 01, 2024 - The racial disparities in maternal mortality and impact of
structural racism and implicit racial bias on pregnant
Black women: a review of the literature.
December 6, 2023
Montalmant KE, Ettinger AK. The racial disparities in maternal mortality and impact of structural racism and
implicit racial bias on pregnant b…
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psnet.ahrq.gov/node/60243/psn-pdf
April 22, 2020 - COVID-19: peer support and crisis communication
strategies to promote institutional resilience.
April 22, 2020
Wu AW, Connors C, Everly GS. COVID-19: Peer Support and Crisis Communication Strategies to Promote
Institutional Resilience. Ann Intern Med. 2020;172(12):822-823. doi:10.7326/m20-1236.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/838625/psn-pdf
October 19, 2022 - Improving communication and response to clinical
deterioration to increase patient safety in the intensive
care unit.
October 19, 2022
Liu SI, Shikar M, Gante E, et al. Improving communication and response to clinical deterioration to increase
patient safety in the intensive care unit. Crit Care Nurse. 2022;42(5):…
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psnet.ahrq.gov/node/47846/psn-pdf
March 06, 2019 - Assessment of the FDA Risk Evaluation and Mitigation
Strategy for transmucosal immediate-release fentanyl
products.
March 6, 2019
Rollman JE, Heyward J, Olson L, et al. Assessment of the FDA Risk Evaluation and Mitigation Strategy for
Transmucosal Immediate-Release Fentanyl Products. JAMA. 2019;321(7):676-685.
do…
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psnet.ahrq.gov/node/34070/psn-pdf
February 18, 2011 - Effect of reducing interns' work hours on serious medical
errors in intensive care units.
February 18, 2011
Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical
errors in intensive care units. N Engl J Med. 2004;351(18):1838-48.
https://psnet.ahrq.gov/issue/effec…
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psnet.ahrq.gov/node/38069/psn-pdf
March 10, 2011 - Evaluating clinical decision support systems: monitoring
CPOE order check override rates in the Department of
Veterans Affairs' computerized patient record system.
March 10, 2011
Lin C-P, Payne TH, Nichol P, et al. Evaluating clinical decision support systems: monitoring CPOE order
check override rates in the Depa…
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psnet.ahrq.gov/node/866860/psn-pdf
October 02, 2024 - Motivation for patient engagement in patient safety: a
multi-perspective, explorative survey.
October 2, 2024
Raab C, Gambashidze N, Brust L, et al. Motivation for patient engagement in patient safety: a multi-
perspective, explorative survey. BMC Health Serv Res. 2024;24(1):1052. doi:10.1186/s12913-024-11495-
x.
…
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psnet.ahrq.gov/node/35647/psn-pdf
June 25, 2010 - Nurse staffing in hospitals: is there a business case for
quality?
June 25, 2010
Needleman J, Buerhaus P, Stewart M, et al. Nurse staffing in hospitals: is there a business case for
quality? Health Aff (Millwood). 2006;25(1):204-11.
https://psnet.ahrq.gov/issue/nurse-staffing-hospitals-there-business-case-quality
…
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psnet.ahrq.gov/node/72799/psn-pdf
March 03, 2021 - Measuring and improving diagnostic safety in primary
care: addressing the “twin” pandemics of diagnostic error
and clinician burnout.
March 3, 2021
Olson APJ, Linzer M, Schiff GD. Measuring and Improving Diagnostic Safety in Primary Care: Addressing
the “Twin” Pandemics of Diagnostic Error and Clinician Burnout. J…
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psnet.ahrq.gov/node/72475/psn-pdf
November 18, 2020 - Omissions of care in nursing homes: a uniform definition
for research and quality improvement.
November 18, 2020
Mangrum R, Stewart MD, Gifford DR, et al. Omissions of care in nursing homes: a uniform definition for
research and quality improvement. J Am Med Dir Assoc. 2020;21(11):1587-1591.e2.
doi:10.1016/j.jamda…