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psnet.ahrq.gov/node/853063/psn-pdf
August 30, 2023 - Exploring medication safety structures and processes in
nursing homes: a cross-sectional study.
August 30, 2023
Favez L, Zúñiga F, Meyer-Massetti C. Exploring medication safety structures and processes in nursing
homes: a cross-sectional study. Int J Clin Pharm. 2023;45(6):1464-1471. doi:10.1007/s11096-023-01625-6.…
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psnet.ahrq.gov/node/42744/psn-pdf
September 01, 2016 - Physicians' responses to clinical decision support on an
intensive care unit—comparison of four different alerting
methods.
September 1, 2016
Scheepers-Hoeks A-MJ, Grouls RJ, Neef C, et al. Physicians' responses to clinical decision support on an
intensive care unit--comparison of four different alerting methods. …
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psnet.ahrq.gov/node/45072/psn-pdf
May 04, 2016 - Interventions to improve safe sleep among hospitalized
infants at eight children's hospitals.
May 4, 2016
Kuhlmann S, Ahlers-Schmidt CR, Lukasiewicz G, et al. Interventions to Improve Safe Sleep Among
Hospitalized Infants at Eight Children's Hospitals. Hosp Pediatr. 2016;6(2):88-94. doi:10.1542/hpeds.2015-
0121.
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psnet.ahrq.gov/node/866279/psn-pdf
July 10, 2024 - Need to systematically identify and mitigate risks upon
hospitalisation for patients with chronic health
conditions.
July 10, 2024
Pronovost PJ, Carrington EM. Need to systematically identify and mitigate risks upon hospitalisation for
patients with chronic health conditions. BMJ Qual Saf. 2024;33(11):755-758. doi…
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psnet.ahrq.gov/node/846759/psn-pdf
March 29, 2023 - A contemporary analysis of closed claims related to
wrong site surgery.
March 29, 2023
Tan J, Ross JM, Wright D, et al. A contemporary analysis of closed claims related to wrong site surgery. Jt
Comm J Qual Patient Saf. 2023;49(5):265-273. doi:10.1016/j.jcjq.2023.02.002.
https://psnet.ahrq.gov/issue/contemporary-a…
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psnet.ahrq.gov/node/50654/psn-pdf
November 13, 2019 - Exploring stakeholder perceptions around
implementation of the Operating Room Black Box for
patient safety research: a qualitative study using the
theoretical domains framework.
November 13, 2019
Etherington N, Usama A, Patey AM, et al. Exploring stakeholder perceptions around implementation of the
Operating Room…
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psnet.ahrq.gov/node/855096/psn-pdf
November 08, 2023 - Systematic workup of transfusion reactions reveals
passive co-reporting of handling errors.
November 8, 2023
Nitsche E, Dreßler J, Henschler R. Systematic workup of transfusion reactions reveals passive co-reporting
of handling errors. J Blood Med. 2023;14:435-443. doi:10.2147/jbm.s411188.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/38309/psn-pdf
December 23, 2016 - Safely implementing health information and converging
technologies.
December 23, 2016
Safely implementing health information and converging technologies. Sentinel event alert. 2008;(42):1-4.
https://psnet.ahrq.gov/issue/safely-implementing-health-information-and-converging-technologies
As health information techno…
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psnet.ahrq.gov/node/851663/psn-pdf
July 26, 2023 - Quality of Care Concerns and the Facility Response
Following a Medical Emergency at the VA Southern
Nevada Health Care System in Las Vegas.
July 26, 2023
Washington, DC: VA Office of the Inspector General; June 28, 2023. Report no. 22-02725-132.
https://psnet.ahrq.gov/issue/quality-care-concerns-and-facility-…
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psnet.ahrq.gov/node/48024/psn-pdf
January 01, 2021 - The mental health trigger tool: development and testing of
a specialized trigger tool for mental health settings.
July 10, 2019
Sajith SG, Fung D, Chua HC. The Mental Health Trigger Tool: Development and Testing of a Specialized
Trigger Tool for Mental Health Settings. J Patient Saf. 2021;17(4):e306-e312.
doi:10.1…
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psnet.ahrq.gov/node/45199/psn-pdf
June 15, 2016 - Towards safer transitions: a curriculum to teach and
assess hospital-to-hospice handoffs.
June 15, 2016
Darrah NJ, O'Connor NR. Toward Safer Transitions: A Curriculum to Teach and Assess Hospital-to-
Hospice Handoffs. J Pain Symptom Manage. 2016;51(6):959-962.e2.
doi:10.1016/j.jpainsymman.2016.01.012.
https://psn…
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psnet.ahrq.gov/node/36813/psn-pdf
March 24, 2011 - Ambulatory care adverse events and preventable adverse
events leading to a hospital admission.
March 24, 2011
Woods D, Thomas EJ, Holl JL, et al. Ambulatory care adverse events and preventable adverse events
leading to a hospital admission. Qual Saf Health Care. 2007;16(2):127-131.
https://psnet.ahrq.gov/issue/amb…
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psnet.ahrq.gov/node/862990/psn-pdf
February 21, 2024 - Assessing the excess costs of the in-hospital adverse
events covered by the AHRQ's Patient Safety Indicators in
Switzerland.
February 21, 2024
Giese A, Khanam R, Nghiem S, et al. Assessing the excess costs of the in-hospital adverse events
covered by the AHRQ’s Patient Safety Indicators in Switzerland. PLoS ONE. 2…
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psnet.ahrq.gov/node/72727/psn-pdf
February 10, 2021 - System factors affecting intraoperative risk and
resilience: applying a novel integrated approach to study
surgical performance and patient safety.
February 10, 2021
Kolodzey L, Trbovich PL, Kashfi A, et al. System Factors Affecting Intraoperative Risk and Resilience. Ann
Surg. 2020;272(6):1164-1170. doi:10.1097/s…
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psnet.ahrq.gov/node/47379/psn-pdf
November 14, 2018 - Analysis of medication therapy discontinuation orders in
new electronic prescriptions and opportunities for
implementing CancelRx.
November 14, 2018
Yang Y, Ward-Charlerie S, Kashyap N, et al. Analysis of medication therapy discontinuation orders in new
electronic prescriptions and opportunities for implementing C…
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psnet.ahrq.gov/node/866163/psn-pdf
June 19, 2024 - Performance evaluation of ChatGPT in detecting
diagnostic errors and their contributing factors: an
analysis of 545 case reports of diagnostic errors.
June 19, 2024
Harada Y, Suzuki T, Harada T, et al. Performance evaluation of ChatGPT in detecting diagnostic errors
and their contributing factors: an analysis of 5…
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psnet.ahrq.gov/node/73136/psn-pdf
April 14, 2021 - Nurse's Achilles Heel: using big data to determine
workload factors that impact near misses.
April 14, 2021
Campbell AA, Harlan T, Campbell M, et al. Nurse's Achilles Heel: using big data to determine workload
factors that impact near misses. J Nurs Scholarsh. 2021;53(3):333-342. doi:10.1111/jnu.12652.
https://psn…
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psnet.ahrq.gov/node/865486/psn-pdf
April 03, 2024 - Clinical informatics team members' perspectives on
health information technology safety after experiential
learning and safety process development: qualitative
descriptive study.
April 3, 2024
Recsky C, Rush KL, MacPhee M, et al. Clinical informatics team members' perspectives on health
information technology saf…
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psnet.ahrq.gov/node/46765/psn-pdf
April 04, 2018 - Advancing perinatal patient safety through application of
safety science principles using health IT.
April 4, 2018
Webb J, Sorensen A, Sommerness SA, et al. Advancing perinatal patient safety through application of
safety science principles using health IT. BMC Med Inform Decis Mak. 2017;17(1):176.
doi:10.1186/s12…
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psnet.ahrq.gov/node/44914/psn-pdf
February 15, 2017 - Safer prescribing—a trial of education, informatics, and
financial incentives.
February 15, 2017
Dreischulte T, Donnan P, Grant A, et al. Safer Prescribing--A Trial of Education, Informatics, and Financial
Incentives. N Engl J Med. 2016;374(11):1053-64. doi:10.1056/NEJMsa1508955.
https://psnet.ahrq.gov/issue/safer…