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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73064/psn-pdf
    March 24, 2021 - Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017. March 24, 2021 Geller AI, Conrad AO, Weidle NJ, et al. Outpatient insulin?related adverse events due to mix?up errors: Findings from two national surveillance systems, United S…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43446/psn-pdf
    May 06, 2015 - A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the "Surgical Checklist Implementation Project." May 6, 2015 Russ SJ, Sevdalis N, Moorthy K, et al. A qualitative evaluation of the barriers and facilitator…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45538/psn-pdf
    December 14, 2016 - Liquid medication errors and dosing tools: a randomized controlled experiment. December 14, 2016 Yin S, Parker RM, Sanders LM, et al. Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment. Pediatrics. 2016;138(4):e20160357. https://psnet.ahrq.gov/issue/liquid-medication-errors-and-dosing-to…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46565/psn-pdf
    January 23, 2019 - Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. January 23, 2019 Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for Healthcare Improvement; 2017. https://psnet.ahrq.gov/issue/closing-loop-guide-safer-ambulatory-referrals-ehr-era Missed an…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36886/psn-pdf
    May 27, 2011 - The extent and importance of unintended consequences related to computerized provider order entry. May 27, 2011 Ash JS, Sittig DF, Poon EG, et al. The extent and importance of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2007;14(4):415-23. https://psnet.ahrq.gov/issu…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44819/psn-pdf
    June 21, 2016 - Opioid prescribing after nonfatal overdose and association with repeated overdose: a cohort study. June 21, 2016 Larochelle MR, Liebschutz JM, Zhang F, et al. Opioid Prescribing After Nonfatal Overdose and Association With Repeated Overdose: A Cohort Study. Ann Inter Med. 2016;164(1):1-9. doi:10.7326/M15-0038. htt…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41028/psn-pdf
    May 14, 2018 - Health care worker fatigue and patient safety. May 14, 2018 Sentinel Event Alert. December 14, 2011;(48):1-4. (addendum May 14, 2018). https://psnet.ahrq.gov/issue/health-care-worker-fatigue-and-patient-safety The Joint Commission issues sentinel event alerts to emphasize pressing safety issues and provide guideli…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44035/psn-pdf
    May 06, 2015 - Insulin pump risks and benefits: a clinical appraisal of pump safety standards, adverse event reporting, and research needs: a joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. May 6, 2015 Heinemann L, Fleming A, Petrie …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45345/psn-pdf
    July 27, 2016 - An official Critical Care Societies Collaborative statement: burnout syndrome in critical care healthcare professionals: a call for action. July 27, 2016 Moss M, Good VS, Gozal D, et al. An Official Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Healthcare Professionals: A Call …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41497/psn-pdf
    April 05, 2013 - Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods. April 5, 2013 Payne CE, Stein JM, Leong T, et al. Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods. BMJ Qual Saf. 2012;21(11):925-32. doi:1…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38175/psn-pdf
    April 11, 2011 - An intervention to decrease narcotic-related adverse drug events in children's hospitals. April 11, 2011 Sharek PJ, McClead RE, Taketomo C, et al. An intervention to decrease narcotic-related adverse drug events in children's hospitals. Pediatrics. 2008;122(4):e861-e866. doi:10.1542/peds.2008-1011. https://psnet.a…

  12. How Patient Narratives Can Support Your Patient Experience Strategy (Webcast) - Quigley (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/05-pt-narratives-support-px-strategy-quigley.pdf
    June 02, 2025 - How Patient Narratives Can Support Your Patient Experience Strategy (Webcast) - Quigley Patient Narrative Research Insights Insights About Child HCAHPS Survey Comments on Pediatric Inpatient Experiences Denise D. Quigley, PhD 19 Children’s Hospital in Academic Medical Center • Child HCAHPS open-ended questi…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41732/psn-pdf
    October 03, 2012 - Double checking the administration of medicines: what is the evidence? A systematic review. October 3, 2012 Alsulami Z, Conroy S, Choonara I. Double checking the administration of medicines: what is the evidence? A systematic review. Arch Dis Child. 2012;97(9):833-7. doi:10.1136/archdischild-2011-301093. https://p…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46450/psn-pdf
    August 20, 2018 - Improving Diagnostic Quality and Safety Final Report. August 20, 2018 Washington, DC: National Quality Forum. September 19, 2017. https://psnet.ahrq.gov/issue/improving-diagnostic-quality-and-safety-final-report Although diagnostic error is a well-recognized source of preventable patient harm, measuring and mitiga…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48057/psn-pdf
    June 26, 2019 - Multicenter study to evaluate the benefits of technology- assisted workflow on i.v. room efficiency, costs, and safety. June 26, 2019 Eckel SF, Higgins JP, Hess E, et al. Multicenter study to evaluate the benefits of technology-assisted workflow on i.v. room efficiency, costs, and safety. Am J Health-Syst Pharm. 2…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851054/psn-pdf
    June 28, 2023 - Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review. June 28, 2023 Ayre MJ, Lewis PJ, Keers RN. Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review. BMC Psychiatry. 2023;23(1):417. doi:10.118…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837193/psn-pdf
    May 25, 2022 - Defining diagnostic error: a scoping review to assess the impact of the National Academies' report Improving Diagnosis in Health Care. May 25, 2022 Giardina TD, Hunte H, Hill MA, et al. Defining diagnostic error: a scoping review to assess the impact of the National Academies' report Improving Diagnosis in Health …

  18. Background Report on 2013 Retirement of Measures from the Child Core Set | Agency for Healthcare Research and Quality

    www.ahrq.gov/policymakers/chipra/measure_retirement/index.html
    February 01, 2014 - Background Report on 2013 Retirement of Measures from the Child Core Set Next Page Table of Contents Background Report on 2013 Retirement of Measures from the Child Core Set Abstract Background Methods Results Conclusions References Appendix A. Appendix B. Appendix C. Appendix D…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44497/psn-pdf
    September 09, 2015 - VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events. September 9, 2015 Washington, DC: United States Government Accountability Office; July 29, 2015. Publication GAO-15-643. https://psnet.ahrq.gov/issue/va-health-care-actions-needed-assess-decrease-root-cause-analyses- advers…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41437/psn-pdf
    January 03, 2017 - Making the transition to nursing bedside shift reports. January 3, 2017 Wakefield DS, Ragan R, Brandt J, et al. Making the transition to nursing bedside shift reports. Jt Comm J Qual Patient Saf. 2012;38(6):243-53. https://psnet.ahrq.gov/issue/making-transition-nursing-bedside-shift-reports Efforts to improve comm…
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