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psnet.ahrq.gov/node/47652/psn-pdf
February 20, 2019 - Strategy on Reducing Regulatory and Administrative
Burden Relating to the Use of Health IT and EHRs.
February 20, 2019
Washington, DC: Office of the National Coordinator for Health Information Technology; November 28,
2018.
https://psnet.ahrq.gov/issue/strategy-reducing-regulatory-and-administrative-burden-relatin…
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psnet.ahrq.gov/node/43108/psn-pdf
September 28, 2023 - Maryland Hospital Patient Safety Program Annual Report.
September 28, 2023
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.
https://psnet.ahrq.gov/issue/maryland-hospital-patient-safety-program-annual-report
This annual report summarizes never events in Maryland hospit…
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psnet.ahrq.gov/node/47013/psn-pdf
April 07, 2019 - An electronic intervention to improve safety for pain
patients co-prescribed chronic opioids and
benzodiazepines.
April 7, 2019
Zaman T, Rife TL, Batki SL, et al. An electronic intervention to improve safety for pain patients co-
prescribed chronic opioids and benzodiazepines. Subst Abus. 2018;39(4):441-448.
doi:…
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psnet.ahrq.gov/node/47024/psn-pdf
November 28, 2018 - FDA Safety Communication: use caution with implanted
pumps for intrathecal administration of medicines for
pain management.
November 28, 2018
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 14, 2018.
https://psnet.ahrq.gov/issue/fda-safety-communication-use-caution-implanted-pum…
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psnet.ahrq.gov/node/41217/psn-pdf
July 02, 2014 - Handoffs in the era of duty hours reform: a focused
review and strategy to address changes in the
Accreditation Council for Graduate Medical Education
Common Program Requirements.
July 2, 2014
DeRienzo CM, Frush K, Barfield ME, et al. Handoffs in the era of duty hours reform: a focused review and
strategy to addr…
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psnet.ahrq.gov/node/44947/psn-pdf
November 18, 2016 - Impact of the 2011 ACGME resident duty hour reform on
hospital patient experience and processes-of-care.
November 18, 2016
Rajaram R, Saadat L, Chung JW, et al. Impact of the 2011 ACGME resident duty hour reform on hospital
patient experience and processes-of-care. BMJ Qual Saf. 2016;25(12):962-970. doi:10.1136/bmj…
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psnet.ahrq.gov/node/46227/psn-pdf
October 30, 2017 - Patient engagement with surgical site infection
prevention: an expert panel perspective.
October 30, 2017
Tartari E, Weterings V, Gastmeier P, et al. Patient engagement with surgical site infection prevention: an
expert panel perspective. Antimicrob Resist Infect Control. 2017;6:45. doi:10.1186/s13756-017-0202-3.
…
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psnet.ahrq.gov/node/60947/psn-pdf
September 23, 2020 - FDA Advise-ERR: reported medication errors with Veklury
(remdesivir) emergency use authorization.
September 23, 2020
ISMP Medication Safety Alert! Acute care edition. September 10, 2020;25(18)
https://psnet.ahrq.gov/issue/fda-advise-err-reported-medication-errors-veklury-remdesivir-emergency-use-
authorizatio…
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psnet.ahrq.gov/node/60013/psn-pdf
March 04, 2020 - Development and implementation of a suicide prevention
checklist to create a safe environment.
March 4, 2020
Frost DA, Snydeman CK, Lantieri MJ, et al. Development and Implementation of a Suicide Prevention
Checklist to Create a Safe Environment. Psychosomatics. 2019;61(2):154-160.
doi:10.1016/j.psym.2019.10.008.
…
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psnet.ahrq.gov/node/34796/psn-pdf
November 18, 2015 - The business case for quality: case studies and an
analysis.
November 18, 2015
Leatherman S, Berwick DM, Iles D, et al. The business case for quality: case studies and an analysis.
Health Aff (Millwood). 2003;22(2):17-30.
https://psnet.ahrq.gov/issue/business-case-quality-case-studies-and-analysis
This comprehens…
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psnet.ahrq.gov/node/44801/psn-pdf
June 22, 2016 - Safety for all: integrated design for inpatient units.
June 22, 2016
Hunt JM, Sine DM. Patient Saf Qual Healthc. May/June 2016;13:20-28.
https://psnet.ahrq.gov/issue/safety-all-integrated-design-inpatient-units
Design is emerging as an important tactic to augment safe care delivery. Hospitals that provide care for
…
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psnet.ahrq.gov/node/46355/psn-pdf
October 09, 2017 - Diagnostic reasoning: an endangered competency in
internal medicine training.
October 9, 2017
Simpkin AL, Vyas JM, Armstrong KA. Diagnostic Reasoning: An Endangered Competency in Internal
Medicine Training. Ann Intern Med. 2017;167(7):507-508. doi:10.7326/M17-0163.
https://psnet.ahrq.gov/issue/diagnostic-reasoning…
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psnet.ahrq.gov/node/41515/psn-pdf
July 02, 2014 - Anticipated consequences of the 2011 duty hours
standards: views of internal medicine and surgery
program directors.
July 2, 2014
Shea JA, Willett LL, Borman KR, et al. Anticipated consequences of the 2011 duty hours standards: views
of internal medicine and surgery program directors. Acad Med. 2012;87(7):895-903.…
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psnet.ahrq.gov/node/47099/psn-pdf
May 16, 2018 - Defense Health Agency Should Improve Tracking of
Serious Adverse Medical Events and Monitoring of
Required Follow-up.
May 16, 2018
Washington, DC: United States Government Accountability Office; April 2018. Publication GAO-18-378.
https://psnet.ahrq.gov/issue/defense-health-agency-should-improve-tracking-serious-a…
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psnet.ahrq.gov/node/47520/psn-pdf
February 06, 2019 - Improving patient safety in developing countries—moving
towards an integrated approach.
February 6, 2019
Elmontsri M, Banarsee R, Majeed A. Improving patient safety in developing countries - moving towards an
integrated approach. JRSM Open. 2018;9(11):2054270418786112. doi:10.1177/2054270418786112.
https://psnet.a…
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psnet.ahrq.gov/node/60974/psn-pdf
September 30, 2020 - Covid-19: Assessing the Risk to Public Protection Posed
by a Doctor as a Result of Concerns about their Practice
during the Pandemic.
September 30, 2020
London, UK: General Medical Council; September 14, 2020.
https://psnet.ahrq.gov/issue/covid-19-assessing-risk-public-protection-posed-doctor-result-concerns-about…
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psnet.ahrq.gov/node/60213/psn-pdf
April 08, 2020 - FDA alerts patients and health care professionals of
EpiPen auto-injector errors related to device malfunctions
and user administration.
April 8, 2020
FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device
malfunctions and user administration. MedWatch Safety Alert. Silv…
-
psnet.ahrq.gov/node/43398/psn-pdf
July 30, 2014 - Strategies to prevent healthcare-associated infections
through hand hygiene.
July 30, 2014
Ellingson K, Haas JP, Aiello AE, et al. Strategies to prevent healthcare-associated infections through hand
hygiene. Infect Control Hosp Epidemiol. 2014;35(8):937-960. doi:10.1086/677145.
https://psnet.ahrq.gov/issue/strateg…
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psnet.ahrq.gov/node/46770/psn-pdf
January 01, 2021 - A transactional "second-victim" model—experiences of
affected healthcare professionals in acute-somatic
inpatient settings: a qualitative metasynthesis.
April 11, 2018
Schiess C, Schwappach DLB, Schwendimann R, et al. A Transactional "Second-Victim" Model-
Experiences of Affected Healthcare Professionals in Acute-…
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psnet.ahrq.gov/node/844802/psn-pdf
September 18, 2019 - Using proactive risk assessment (HFMEA) to improve
patient safety and quality associated with intraocular lens
selection and implantation in cataract surgery.
September 18, 2019
DeRosier JM, Hansemann BK, Smith-Wheelock MW, et al. Using Proactive Risk Assessment (HFMEA) to
Improve Patient Safety and Quality Associ…