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psnet.ahrq.gov/node/39280/psn-pdf
February 10, 2010 - Effects of extended work shifts and shift work on patient
safety, productivity, and employee health.
February 10, 2010
Keller SM. Effects of extended work shifts and shift work on patient safety, productivity, and employee
health. AAOHN J. 2009;57(12):497-504. doi:10.3928/08910162-20091124-05.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/38614/psn-pdf
February 15, 2011 - Effect of a pharmacist on adverse drug events and
medication errors in outpatients with cardiovascular
disease.
February 15, 2011
Murray MD, Ritchey ME, Wu J, et al. Effect of a pharmacist on adverse drug events and medication errors
in outpatients with cardiovascular disease. Arch Intern Med. 2009;169(8):757-63.
…
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psnet.ahrq.gov/node/44126/psn-pdf
May 13, 2015 - SAFER Electronic Health Records: Safety Assurance
Factors for EHR Resilience.
May 13, 2015
Sittig DF, Singh H, eds. Waretown, NJ: Apple Academic Press; 2015. ISBN: 9781771881173.
https://psnet.ahrq.gov/issue/safer-electronic-health-records-safety-assurance-factors-ehr-resilience
Implementation of electronic health…
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psnet.ahrq.gov/node/50822/psn-pdf
January 22, 2020 - Nurses' sleep, work hours, and patient care quality, and
safety
January 22, 2020
Stimpfel AW, Fatehi F, Kovner C. Sleep Health. 2020;6(3):314-320.
https://psnet.ahrq.gov/issue/nurses-sleep-work-hours-and-patient-care-quality-and-safety
Research provides evidence that sleep deprivation among nurses is a threat to p…
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psnet.ahrq.gov/node/43335/psn-pdf
July 09, 2014 - Wake Up Safe and root cause analysis: quality
improvement in pediatric anesthesia.
July 9, 2014
Tjia I, Rampersad S, Varughese AM, et al. Wake Up Safe and root cause analysis: quality improvement in
pediatric anesthesia. Anesth Analg. 2014;119(1):122-136. doi:10.1213/ANE.0000000000000266.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/36615/psn-pdf
January 14, 2011 - The Patient Safety and Quality Improvement Act of 2005:
provisions and potential opportunities.
January 14, 2011
Liang BA, Riley W, Rutherford W, et al. The Patient Safety and Quality Improvement Act of 2005:
Provisions and Potential Opportunities. American Journal of Medical Quality. 2007;22(1).
doi:10.1177/10628…
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psnet.ahrq.gov/node/42677/psn-pdf
July 16, 2015 - Using "near misses" analysis to prevent wrong-site
surgery.
July 16, 2015
Yoon RS, Alaia MJ, Hutzler LH, et al. Using "near misses" analysis to prevent wrong-site surgery. J Healthc
Qual. 2015;37(2):126-32. doi:10.1111/jhq.12037.
https://psnet.ahrq.gov/issue/using-near-misses-analysis-prevent-wrong-site-surgery
B…
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psnet.ahrq.gov/node/39481/psn-pdf
September 29, 2017 - The natural lifespan of a safety policy: violations and
system migration in anaesthesia.
September 29, 2017
Maurice G de S, Auroy Y, Vincent CA, et al. The natural lifespan of a safety policy: violations and system
migration in anaesthesia. Qual Saf Health Care. 2010;19(4):327-31. doi:10.1136/qshc.2008.029959.
htt…
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psnet.ahrq.gov/node/36040/psn-pdf
June 21, 2006 - Morphine overdose from error propagation on an acute
pain service: [Une surdose de morphine resultant de
multiples erreurs dans un service de douleur aigue].
June 21, 2006
Syed S; Paul JE; Hueftlein M; Kampf M; McLean RF.
https://psnet.ahrq.gov/issue/morphine-overdose-error-propagation-acute-pain-service-une-surdo…
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psnet.ahrq.gov/node/38226/psn-pdf
February 18, 2011 - Critical events in the lives of interns.
February 18, 2011
Ackerman A, Graham M, Schmidt H, et al. Critical events in the lives of interns. J Gen Intern Med.
2009;24(1):27-32. doi:10.1007/s11606-008-0769-8.
https://psnet.ahrq.gov/issue/critical-events-lives-interns
Resident physicians remain at high risk for burno…
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psnet.ahrq.gov/node/47829/psn-pdf
March 27, 2019 - The impact of internal service quality on preventable
adverse events in hospitals.
March 27, 2019
Zheng S, Tucker AL, Ren ZJ, et al. The Impact of Internal Service Quality on Preventable Adverse Events
in Hospitals. Production Operations Manag. 2017;27(12):2201-2212. doi:10.1111/poms.12758.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/36223/psn-pdf
May 27, 2011 - Prescribers' responses to alerts during medication
ordering in the long term care setting.
May 27, 2011
Judge J, Field T, DeFlorio M, et al. Prescribers' responses to alerts during medication ordering in the long
term care setting. J Am Med Inform Assoc. 2006;13(4):385-90.
https://psnet.ahrq.gov/issue/prescribers-…
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psnet.ahrq.gov/node/43657/psn-pdf
November 26, 2014 - Strategies for Ensuring the Safe Use of Insulin Pens in the
Hospital.
November 26, 2014
American Society of Health-System Pharmacists
https://psnet.ahrq.gov/issue/strategies-ensuring-safe-use-insulin-pens-hospital
Insulin is classified as a high-alert medication due to the potential to cause serious patient harm w…
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psnet.ahrq.gov/node/837907/psn-pdf
August 24, 2022 - ISMP Guidelines for Safe Medication Use in Perioperative
and Procedural Settings.
August 24, 2022
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.
https://psnet.ahrq.gov/issue/ismp-guidelines-safe-medication-use-perioperative-and-procedural-settings
Medication errors associated with surgery and…
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psnet.ahrq.gov/node/838639/psn-pdf
October 19, 2022 - Calibrate Dx: A Resource to Improve Diagnostic
Decisions.
October 19, 2022
Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)-
0047-2-EF.
https://psnet.ahrq.gov/issue/calibrate-dx-resource-improve-diagnostic-decisions
Delayed, wrong, and missed diagnoses are commo…
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psnet.ahrq.gov/node/44846/psn-pdf
August 31, 2016 - Making health care safer: protect patients from antibiotic
resistance.
August 31, 2016
CDC; Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/making-health-care-safer-protect-patients-antibiotic-resistance
Health care–associated infections (HAI) are a worldwide patient safety problem. This a…
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psnet.ahrq.gov/node/44488/psn-pdf
September 16, 2015 - Environmental Cleaning for the Prevention of Healthcare-
Associated Infections (HAIs).
September 16, 2015
Leas BF, Sullivan N, Han JH, Pegues DA, Kaczmarek JL, Umscheid CA. Rockville, MD: Agency for
Healthcare Research and Quality; August 2015. Technical Brief No. 22. AHRQ Publication No. 15-
EHC020-EF.
https://p…
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psnet.ahrq.gov/node/41838/psn-pdf
December 04, 2016 - Modern palliative radiation treatment: do complexity and
workload contribute to medical errors?
December 4, 2016
D'Souza N, Holden L, Robson S, et al. Modern palliative radiation treatment: do complexity and workload
contribute to medical errors? Int J Radiat Oncol Biol Phys. 2012;84(1):e43-8.
doi:10.1016/j.ijrobp…
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psnet.ahrq.gov/node/45386/psn-pdf
November 23, 2016 - Balancing doctor egos and errors.
November 23, 2016
Sweeney JF. Medical Economics. November 10, 2016.
https://psnet.ahrq.gov/issue/balancing-doctor-egos-and-errors
Disclosure and candor with patients after a medical error has gained support from organizations, clinicians,
and patients. This magazine article discus…
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psnet.ahrq.gov/node/41051/psn-pdf
February 20, 2012 - What do patients and relatives know about problems and
failures in care?
February 20, 2012
Iedema R, Allen S, Britton K, et al. What do patients and relatives know about problems and failures in
care? BMJ Qual Saf. 2012;21(3):198-205. doi:10.1136/bmjqs-2011-000100.
https://psnet.ahrq.gov/issue/what-do-patients-and…