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psnet.ahrq.gov/issue/when-doctor-too-old-job
March 04, 2020 - Newspaper/Magazine Article
When is a doctor too old for the job?
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September 18, 2019
Potential deterioration of an aging surgeon's…
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psnet.ahrq.gov/node/42412/psn-pdf
October 07, 2013 - Quality and safety implications of emergency department
information systems.
October 7, 2013
Farley HL, Baumlin KM, Hamedani A, et al. Quality and safety implications of emergency department
information systems. Ann Emerg Med. 2013;62(4):399-407. doi:10.1016/j.annemergmed.2013.05.019.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/61114/psn-pdf
November 11, 2020 - A mixed-methods analysis of patient safety incidents
involving opioid substitution treatment with methadone or
buprenorphine in community-based care in England and
Wales.
November 11, 2020
Gibson R, MacLeod N, Donaldson LJ, et al. A mixed?methods analysis of patient safety incidents involving
opioid substitution …
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psnet.ahrq.gov/node/864858/psn-pdf
March 20, 2024 - Remote assessment of real-world surgical safety
checklist performance using the OR Black Box: a multi-
institutional evaluation.
March 20, 2024
Riley MS, Etheridge J, Palter V, et al. Remote assessment of real-world surgical safety checklist
performance using the OR Black Box: a multi-Institutional evaluation. J A…
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psnet.ahrq.gov/node/47282/psn-pdf
August 08, 2018 - Making surgical wards safer for patients with diabetes:
reducing hypoglycaemia and insulin errors.
August 8, 2018
Singh A, Adams A, Dudley B, et al. Making surgical wards safer for patients with diabetes: reducing
hypoglycaemia and insulin errors. BMJ Open Qual. 2018;7(3):e000312. doi:10.1136/bmjoq-2017-000312.
ht…
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psnet.ahrq.gov/node/45872/psn-pdf
April 13, 2017 - Finding diagnostic errors in children admitted to the
PICU.
April 13, 2017
Davalos MC, Samuels K, Meyer AND, et al. Finding diagnostic errors in children admitted to the PICU.
Pediatr Crit Care Med. 2017;18(3):265-271. doi:10.1097/PCC.0000000000001059.
https://psnet.ahrq.gov/issue/finding-diagnostic-errors-childre…
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psnet.ahrq.gov/node/74833/psn-pdf
February 16, 2022 - Performance of a trigger tool for detecting drug-related
hospital admissions in older people: analysis from the
OPERAM trial.
February 16, 2022
Zerah L, Henrard S, Thevelin S, et al. Performance of a trigger tool for detecting drug-related hospital
admissions in older people: analysis from the OPERAM trial. Age Ag…
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psnet.ahrq.gov/node/866864/psn-pdf
October 02, 2024 - Patient safety in actioning and communicating blood test
results in primary care: a UK wide audit using the Primary
Care Academic CollaboraTive (PACT).
October 2, 2024
Watson J, Duncan P, Burrell A, et al. Patient safety in actioning and communicating blood test results in
primary care: a UK wide audit using the P…
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psnet.ahrq.gov/node/44103/psn-pdf
July 08, 2015 - Results of survey on pediatric medication safety—part 1
and part 2.
July 8, 2015
ISMP Medication Safety Alert! Acute Care Edition. June 4, 2015;20:1-6. July 2, 2015;20:1-5.
https://psnet.ahrq.gov/issue/results-survey-pediatric-medication-safety-part-1-and-part-2
Hospitalized children are susceptible to medication …
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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…
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psnet.ahrq.gov/node/48193/psn-pdf
August 28, 2019 - Automated detection of wrong-drug prescribing errors.
August 28, 2019
Lambert BL, Galanter W, Liu KL, et al. Automated detection of wrong-drug prescribing errors. BMJ Qual
Saf. 2019;28(11):908-915. doi:10.1136/bmjqs-2019-009420.
https://psnet.ahrq.gov/issue/automated-detection-wrong-drug-prescribing-errors
Look-al…
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psnet.ahrq.gov/node/44965/psn-pdf
February 15, 2017 - Identification and Prioritization of Health IT Patient Safety
Measures.
February 15, 2017
Washington, DC: National Quality Forum; February 2016.
https://psnet.ahrq.gov/issue/identification-and-prioritization-health-it-patient-safety-measures
Health information technology (IT) has transformed health care and improv…
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psnet.ahrq.gov/node/36150/psn-pdf
September 29, 2010 - Nurse-physician communication during labor and birth:
implications for patient safety.
September 29, 2010
Simpson KR, James DC, Knox E. Nurse-physician communication during labor and birth: implications for
patient safety. J Obstet Gynecol Neonatal Nurs. 2006;35(4):547-56.
https://psnet.ahrq.gov/issue/nurse-physic…
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psnet.ahrq.gov/node/42169/psn-pdf
September 07, 2016 - National survey on the effect of oncology drug shortages
on cancer care.
September 7, 2016
McBride A, Holle LM, Westendorf C, et al. National survey on the effect of oncology drug shortages on
cancer care. Am J Health Syst Pharm. 2013;70(7):609-17. doi:10.2146/ajhp120563.
https://psnet.ahrq.gov/issue/national-surv…
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psnet.ahrq.gov/node/846449/psn-pdf
March 22, 2023 - Healthcare professionals' perception of safety culture and
the Operating Room (OR) Black Box technology before
clinical implementation: a cross-sectional survey.
March 22, 2023
Strandbygaard J, Dose N, Moeller KE, et al. Healthcare professionals’ perception of safety culture and the
Operating Room (OR) Black Box t…
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psnet.ahrq.gov/node/72670/psn-pdf
January 27, 2021 - System issues leading to "found-on-floor" incidents: a
multi-incident analysis.
January 27, 2021
Shaw J, Bastawrous M, Burns S, et al. System Issues Leading to “Found-on-Floor” Incidents: A Multi-
Incident Analysis. J Patient Saf. 2021;17(1):30-35. doi:10.1097/pts.0000000000000294.
https://psnet.ahrq.gov/issue/sys…
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psnet.ahrq.gov/node/41898/psn-pdf
December 05, 2012 - Pharmacy dispensing of electronically discontinued
medications.
December 5, 2012
Allen AS, Sequist TD. Pharmacy dispensing of electronically discontinued medications. Ann Intern Med.
2012;157(10):700-705. doi:10.7326/0003-4819-157-10-201211200-00006.
https://psnet.ahrq.gov/issue/pharmacy-dispensing-electronically-…
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psnet.ahrq.gov/node/43707/psn-pdf
November 26, 2014 - America's Hospitals: Improving Quality and Safety: The
Joint Commission's Annual Report 2014.
November 26, 2014
Oakbrook Terrace, IL: The Joint Commission; November 2014.
https://psnet.ahrq.gov/issue/americas-hospitals-improving-quality-and-safety-joint-commissions-annual-
report-2014
This Joint Commission annual…
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psnet.ahrq.gov/node/867084/psn-pdf
November 06, 2024 - Effectiveness of artificial intelligence (AI) in clinical
decision support systems and care delivery.
November 6, 2024
Ouanes K, Farhah N. Effectiveness of artificial intelligence (AI) in clinical decision support systems and
care delivery. J Med Syst. 2024;48(1):74. doi:10.1007/s10916-024-02098-4.
https://psnet.a…
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psnet.ahrq.gov/node/40993/psn-pdf
December 14, 2011 - Anticoagulation-associated adverse drug events.
December 14, 2011
Piazza G, Nguyen TN, Cios D, et al. Anticoagulation-associated Adverse Drug Events. Am J Med.
2011;124(12). doi:10.1016/j.amjmed.2011.06.009.
https://psnet.ahrq.gov/issue/anticoagulation-associated-adverse-drug-events
Warfarin and other anticoagulan…