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psnet.ahrq.gov/node/837335/psn-pdf
June 08, 2022 - Root cause analysis using the prevention and recovery
information system for monitoring and analysis method in
healthcare facilities: a systematic literature review.
June 8, 2022
Driesen BEJM, Baartmans M, Merten H, et al. Root cause analysis using the prevention and recovery
information system for monitoring and …
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psnet.ahrq.gov/node/838127/psn-pdf
September 21, 2022 - Opioid dependence and overdose after surgery: rate, risk
factors, and reasons.
September 21, 2022
Wylie JA, Kong L, Barth RJ. Opioid dependence and overdose after surgery: rate, risk factors, and
reasons. Ann Surg. 2022;276(3):e192-e198. doi:10.1097/sla.0000000000005546.
https://psnet.ahrq.gov/issue/opioid-depende…
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psnet.ahrq.gov/node/852455/psn-pdf
August 16, 2023 - A quality improvement initiative to improve pediatric
discharge medication safety and efficiency.
August 16, 2023
Ring LM, Cinotti J, Hom LA, et al. A quality improvement initiative to improve pediatric discharge
medication safety and efficiency. Pediatr Qual Saf. 2023;8(4):e671. doi:10.1097/pq9.0000000000000671.
…
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psnet.ahrq.gov/node/845652/psn-pdf
March 14, 2023 - Controlled substance drug diversion by healthcare
workers as a threat to patient safety.
March 14, 2023
ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4):1-4; March 9, 2023:28(5):1-4.
https://psnet.ahrq.gov/issue/controlled-substance-drug-diversion-healthcare-workers-threat-patient-safety
D…
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psnet.ahrq.gov/node/38579/psn-pdf
February 18, 2011 - Transitions of Care Consensus Policy Statement
American College of Physicians-Society of General
Internal Medicine-Society of Hospital Medicine-American
Geriatrics Society-American College of Emergency
Physicians-Society of Academic Emergency Medicine.
February 18, 2011
Snow V, Beck D, Budnitz T, et al. Transitio…
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psnet.ahrq.gov/node/44202/psn-pdf
June 10, 2015 - Medication reconciliation to facilitate transitions of care
after hospitalization.
June 10, 2015
Liu VC, Garwood CL. Medication reconciliation to facilitate transitions of care after hospitalization. Am J
Health Syst Pharm. 2015;72(9):690-693. doi:10.2146/ajhp140133.
https://psnet.ahrq.gov/issue/medication-reconci…
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psnet.ahrq.gov/node/838240/psn-pdf
October 05, 2022 - Potentially inappropriate prescribing for adults living with
diabetes mellitus: a scoping review.
October 5, 2022
Ayalew MB, Spark MJ, Quirk F, et al. Potentially inappropriate prescribing for adults living with diabetes
mellitus: a scoping review. Int J Clin Pharm. 2022;44(4):860-872. doi:10.1007/s11096-022-01414-…
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psnet.ahrq.gov/node/74074/psn-pdf
November 17, 2021 - How safe is prehospital care? A systematic review.
November 17, 2021
O’Connor P, O’malley R, Lambe KA, et al. How safe is prehospital care? A systematic review. Int J Qual
Health Care. 2021;33(4):mzab138. doi:10.1093/intqhc/mzab138.
https://psnet.ahrq.gov/issue/how-safe-prehospital-care-systematic-review
Patient s…
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psnet.ahrq.gov/node/851065/psn-pdf
June 28, 2023 - Patient safety of perioperative medication through the
lens of digital health and artificial intelligence.
June 28, 2023
Ye J. Patient safety of perioperative medication through the lens of digital health and artificial intelligence.
JMIR Periop Med. 2023;6:e34453. doi:10.2196/34453.
https://psnet.ahrq.gov/issue/p…
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psnet.ahrq.gov/node/60730/psn-pdf
January 01, 2021 - A machine learning approach to reclassifying
miscellaneous patient safety event reports.
July 29, 2020
Fong A, Behzad S, Pruitt Z, et al. A machine learning approach to reclassifying miscellaneous patient
safety event reports. J Patient Saf. 2021;17(8):e829-e833. doi:10.1097/pts.0000000000000731.
https://psnet.ahr…
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psnet.ahrq.gov/node/47631/psn-pdf
March 27, 2019 - Assessing the effectiveness of engaging patients and
their families in the three-step fall prevention process
across modalities of an evidence-based fall prevention
toolkit: an implementation science study.
March 27, 2019
Duckworth M, Adelman JS, Belategui K, et al. Assessing the Effectiveness of Engaging Patients…
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psnet.ahrq.gov/node/46099/psn-pdf
May 31, 2017 - A quality improvement approach to standardization and
sustainability of the hand-off process.
May 31, 2017
Fryman C, Hamo C, Raghavan S, et al. A Quality Improvement Approach to Standardization and
Sustainability of the Hand-off Process. BMJ Qual Improv Rep. 2017;6(1).
doi:10.1136/bmjquality.u222156.w8291.
https:…
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psnet.ahrq.gov/node/863760/psn-pdf
March 06, 2024 - Imagining improved interactions: patients' designs to
address implicit bias.
March 6, 2024
Yang C, Coney L, Mohanraj D, et al. AMIA Annu Symp Proc. 2023;2023:774-783.
https://psnet.ahrq.gov/issue/imagining-improved-interactions-patients-designs-address-implicit-bias
Implicit biases can compromise decision making a…
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psnet.ahrq.gov/node/853612/psn-pdf
September 20, 2023 - Pharmacy e-prescription dispensing before and after
CancelRx implementation.
September 20, 2023
Pitts SI, Olson S, Yanek LR, et al. Pharmacy e-prescription dispensing before and after CancelRx
implementation. JAMA Intern Med. 2023;183(10):1120-1126. doi:10.1001/jamainternmed.2023.4192.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/43311/psn-pdf
July 02, 2014 - Some IV medications are diluted unnecessarily in patient
care areas, creating undue risk.
July 2, 2014
ISMP Medication Safety Alert! Acute Care Edition. June 19, 2014;19:1-5.
https://psnet.ahrq.gov/issue/some-iv-medications-are-diluted-unnecessarily-patient-care-areas-creating-
undue-risk
This newsletter article …
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psnet.ahrq.gov/node/42916/psn-pdf
February 05, 2014 - Are autopsy findings still relevant to the management of
critically ill patients in the modern era?
February 5, 2014
Fröhlich S, Ryan O, Murphy N, et al. Are autopsy findings still relevant to the management of critically ill
patients in the modern era? Crit Care Med. 2014;42(2):336-43. doi:10.1097/CCM.0b013e3182a2…
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psnet.ahrq.gov/node/45292/psn-pdf
September 07, 2016 - Electronic approaches to making sense of the text in the
adverse event reporting system.
September 7, 2016
Benin AL, Fodeh SJ, Lee K, et al. Electronic approaches to making sense of the text in the adverse event
reporting system. J Healthc Risk Manag. 2016;36(2):10-20. doi:10.1002/jhrm.21237.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/45996/psn-pdf
May 10, 2017 - Evaluation of medication-related clinical decision support
alert overrides in the intensive care unit.
May 10, 2017
Wong A, Amato MG, Seger DL, et al. Evaluation of medication-related clinical decision support alert
overrides in the intensive care unit. J Crit Care. 2017;39:156-161. doi:10.1016/j.jcrc.2017.02.027.
…
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psnet.ahrq.gov/node/837059/psn-pdf
May 11, 2022 - Anti-black racism as a chronic condition.
May 11, 2022
Sederstrom N, Lasege T. Anti-black racism as a chronic condition. Hastings Cent Rep. 2022;52(S1):s24-
s29. doi:10.1002/hast.1364.
https://psnet.ahrq.gov/issue/anti-black-racism-chronic-condition
Racial bias and systemic racism in healthcare are increasingly se…
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psnet.ahrq.gov/node/47823/psn-pdf
March 13, 2019 - Greater Focus on Credentialing Needed to Prevent
Disqualified Providers From Delivering Patient Care.
March 13, 2019
Washington, DC: United States Government Accountability Office; February 2019. Publication GAO-19-6.
https://psnet.ahrq.gov/issue/greater-focus-credentialing-needed-prevent-disqualified-providers-del…