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psnet.ahrq.gov/issue/fda-safety-communication-use-caution-implanted-pumps-intrathecal-administration-medicines
June 20, 2018 - Press Release/Announcement
FDA Safety Communication: use caution with implanted pumps for intrathecal administration of medicines for pain management.
Citation Text:
FDA Safety Communication: use caution with implanted pumps for intrathecal administration of medicines for pain management…
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psnet.ahrq.gov/issue/design-endoscopic-retrograde-cholangiopancreatography-ercp-duodenoscopes-may-impede-effective
March 11, 2015 - Government Resource
Design of endoscopic retrograde cholangiopancreatography (ERCP) duodenoscopes may impede effective cleaning.
Citation Text:
Design of endoscopic retrograde cholangiopancreatography (ERCP) duodenoscopes may impede effective cleaning. FDA Safety Communication. Silver Sp…
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psnet.ahrq.gov/issue/exploring-potential-using-drug-indications-prevent-look-alike-and-sound-alike-drug-errors
December 18, 2019 - Study
Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors.
Citation Text:
Seoane-Vazquez E, Rodriguez-Monguio R, Alqahtani S, et al. Exploring the potential for using drug indications to prevent look-alike and sound-alike drug errors. Expe…
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psnet.ahrq.gov/issue/perspective-ten-thousand-hours-patient-safety-sooner-or-later
June 23, 2009 - Commentary
Perspective: ten thousand hours to patient safety, sooner or later.
Citation Text:
Pellegrini VD. Perspective: ten thousand hours to patient safety, sooner or later. Acad Med. 2012;87(2):164-7. doi:10.1097/ACM.0b013e31823f7202.
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psnet.ahrq.gov/issue/fatal-consequences-simple-mistake-how-can-patient-be-saved-inadvertent-intrathecal
January 29, 2020 - Commentary
Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine?
Citation Text:
Reddy K, Brown B, Nanda A. Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine? Clin Neurol Neu…
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psnet.ahrq.gov/issue/new-world-patient-safety-23rd-annual-samuel-jason-mixter-lecture
November 02, 2014 - Commentary
New world of patient safety. 23rd Annual Samuel Jason Mixter Lecture.
Citation Text:
Leape L. New world of patient safety: 23rd Annual Samuel Jason Mixter lecture. Arch Surg. 2009;144(5):394-8. doi:10.1001/archsurg.2009.78.
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psnet.ahrq.gov/issue/hospira-carpuject-pre-filled-cartridges-drug-alert-products-may-contain-more-intended-fill
August 05, 2020 - Press Release/Announcement
Hospira Carpuject pre-filled cartridges—drug alert: products may contain more than the intended fill volume.
Citation Text:
Hospira Carpuject pre-filled cartridges—drug alert: products may contain more than the intended fill volume. MedWatch Safety Alert. S…
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psnet.ahrq.gov/issue/diagnostic-error-critically-ill-defining-problem-and-exploring-next-steps-advance-intensive
January 24, 2024 - Commentary
Diagnostic error in the critically ill: defining the problem and exploring next steps to advance intensive care unit safety.
Citation Text:
Bergl PA, Nanchal RS, Singh H. Diagnostic Error in the Critically III: Defining the Problem and Exploring Next Steps to Advance Intensive…
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psnet.ahrq.gov/issue/recognition-and-management-potential-drug-drug-interactions-patients-internal-medicine-wards
October 21, 2015 - Study
Recognition and management of potential drug-drug interactions in patients on internal medicine wards.
Citation Text:
Vonbach P, Dubied A, Beer JH, et al. Recognition and management of potential drug-drug interactions in patients on internal medicine wards. Eur J Clin Pharmacol. …
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psnet.ahrq.gov/issue/medication-errors-paediatric-care-systematic-review-epidemiology-and-evaluation-evidence
September 09, 2008 - Review
Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations.
Citation Text:
Miller MR, Robinson K, Lubomski LH, et al. Medication errors in paediatric care: a systematic review of epidemiol…
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psnet.ahrq.gov/issue/isolation-precautions-visitors
March 02, 2014 - Organizational Policy/Guidelines
Isolation precautions for visitors.
Citation Text:
Munoz-Price LS, Banach DB, Bearman G, et al. Isolation Precautions for Visitors. Infect Control Hosp Epidemiol. 2015;36(7):747-758. doi:10.1017/ice.2015.67.
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psnet.ahrq.gov/issue/improving-diagnosis-health-care
September 12, 2018 - Book/Report
Classic
Improving Diagnosis in Health Care.
Citation Text:
Improving Diagnosis in Health Care. Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2015. ISB…
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psnet.ahrq.gov/issue/critical-need-nursing-education-address-diagnostic-process
June 08, 2022 - Commentary
The critical need for nursing education to address the diagnostic process.
Citation Text:
Gleason KT, Harkless G, Stanley J, et al. The critical need for nursing education to address the diagnostic process. Nurs Outlook. 2021;69(3):362-369. doi:10.1016/j.outlook.2020.12.005.
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psnet.ahrq.gov/issue/workarounds-intended-use-health-information-technology-narrative-review-human-factors
July 24, 2013 - Review
Emerging Classic
Workarounds to intended use of health information technology: a narrative review of the human factors engineering literature.
Citation Text:
Patterson ES. Workarounds to Intended Use of Health Information Technology: A Narrative Review of…
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psnet.ahrq.gov/issue/guidelines-human-factors-critical-situations-2023
November 29, 2023 - Organizational Policy/Guidelines
Guidelines on Human Factors in Critical Situations 2023.
Citation Text:
Bijok B, Jaulin F, Picard J, et al. Guidelines on human factors in critical situations 2023. Anaesth Crit Care Pain Med. 2023;42(4):101262. doi:10.1016/j.accpm.2023.101262.
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psnet.ahrq.gov/issue/advising-patients-about-patient-safety-current-initiatives-risk-shifting-responsibility
May 20, 2015 - Commentary
Advising patients about patient safety: current initiatives risk shifting responsibility.
Citation Text:
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.…
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www.ahrq.gov/programs/index.html
January 01, 2016 - Digital Healthcare Research Advancing healthcare quality, safety, and effectiveness through the evolving digital healthcare ecosystem. More
PSNet Discover the latest literature, news, and expert commentary on patient safety topics. More
CAHPS The CAHPS program aims to advance our scientific …
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digital.ahrq.gov/health-care-theme/preventive-medicine
January 01, 2023 - Preventive Medicine
Disseminating and Implementing MedSMA℞T Families in Emergency Departments: A Randomized Control Trial to Assess Effectiveness of an Evidence-Based Gaming Intervention to Reduce Opioid Misuse
Description
This research tests the effectiveness of MedSMA℞T Mobi…
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psnet.ahrq.gov/issue/evaluation-clinical-practice-guidelines-fall-prevention-and-management-older-adults
March 09, 2022 - Review
Evaluation of clinical practice guidelines on fall prevention and management for older adults: a systematic review.
Citation Text:
Montero-Odasso MM, Kamkar N, Pieruccini-Faria F, et al. Evaluation of clinical practice guidelines on fall prevention and management for older adults:…
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psnet.ahrq.gov/issue/physician-and-nurse-well-being-patient-safety-and-recommendations-interventions-cross
September 09, 2020 - Study
Physician and nurse well-being, patient safety and recommendations for interventions: cross-sectional survey in hospitals in six European countries.
Citation Text:
Physician and nurse well-being, patient safety and recommendations for interventions: cross-sectional survey in hospit…