-
psnet.ahrq.gov/node/60542/psn-pdf
May 27, 2020 - CPOE has evolved, the addition of
clinical decision support systems has enhanced patient safety and reduced
-
psnet.ahrq.gov/node/39793/psn-pdf
August 25, 2010 - Infection Control in the Intensive Care Unit.
August 25, 2010
Crit Care Med. 2010;38:S265-S404.
https://psnet.ahrq.gov/issue/infection-control-intensive-care-unit
Articles in this special issue describe strategies to reduce infections in the intensive care unit, including
human factors design, guideline use…
-
psnet.ahrq.gov/node/34137/psn-pdf
February 06, 2018 - Anesthesia Patient Safety Foundation.
February 6, 2018
P.O. Box 6668, Rochester, MN 55903.
https://psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation
The Anesthesia Patient Safety Foundation's (APSF) mission is to ensure that no patient is harmed by the
effects of anesthesia. To achieve that mission, APSF s…
-
psnet.ahrq.gov/node/36077/psn-pdf
July 05, 2006 - Perinatal patient safety from the perspective of nurse
executives: a round table discussion.
July 5, 2006
Thorman KE; Capitulo KL; Dubow J; Hanold K; Noonan M; Wehmeyer J.
https://psnet.ahrq.gov/issue/perinatal-patient-safety-perspective-nurse-executives-round-table-discussion
The authors summarize a discussion be…
-
psnet.ahrq.gov/node/41831/psn-pdf
December 31, 2012 - The economics of health care quality and medical errors.
December 31, 2012
Andel C, Davidow SL, Hollander M, et al. The economics of health care quality and medical errors. J Health
Care Finance. 2012;39(1):39-50.
https://psnet.ahrq.gov/issue/economics-health-care-quality-and-medical-errors
Discussing the financia…
-
psnet.ahrq.gov/node/38475/psn-pdf
March 10, 2011 - Effect of alerts for drug dosage adjustment in inpatients
with renal insufficiency.
March 10, 2011
Sellier E, Colombet I, Sabatier B, et al. Effect of alerts for drug dosage adjustment in inpatients with renal
insufficiency. J Am Med Inform Assoc. 2009;16(2):203-10. doi:10.1197/jamia.M2805.
https://psnet.ahrq.gov/…
-
psnet.ahrq.gov/node/50726/psn-pdf
December 11, 2019 - Toolkit To Improve Antibiotic Use in Acute Care Hospitals
December 11, 2019
Agency for Healthcare Research and Quality. 2019.
https://psnet.ahrq.gov/issue/toolkit-improve-antibiotic-use-acute-care-hospitals
Structured processes are important strategies for embedding safe care practices. This tool kit shares
traini…
-
psnet.ahrq.gov/node/38984/psn-pdf
September 30, 2009 - Hospitalist handoffs: a systematic review and task force
recommendations.
September 30, 2009
Arora VM, Manjarrez E, Dressler DD, et al. Hospitalist handoffs: A systematic review and task force
recommendations. J Hosp Med. 2009;4(7). doi:10.1002/jhm.573.
https://psnet.ahrq.gov/issue/hospitalist-handoffs-systematic-…
-
psnet.ahrq.gov/node/41508/psn-pdf
July 11, 2012 - Complications in surgery: root cause analysis and
preventive measures.
July 11, 2012
Chung KC, Kotsis S. Complications in surgery: root cause analysis and preventive measures. Plast
Reconstr Surg. 2012;129(6):1421-1427. doi:10.1097/PRS.0b013e31824ecda0.
https://psnet.ahrq.gov/issue/complications-surgery-root-cause…
-
psnet.ahrq.gov/node/41617/psn-pdf
August 22, 2012 - Medical devices and patient safety.
August 22, 2012
Mattox E. Medical devices and patient safety. Crit Care Nurse. 2012;32(4):60-8. doi:10.4037/ccn2012925.
https://psnet.ahrq.gov/issue/medical-devices-and-patient-safety
This commentary discusses errors associated with medical device use in intensive care environmen…
-
psnet.ahrq.gov/node/41691/psn-pdf
September 19, 2012 - Events associated with the prescribing, dispensing, and
administering of medication loading doses.
September 19, 2012
Carson SL, Gaunt MJ. PA-PSRS Patient Saf Advis. 2012;9:82-88.
https://psnet.ahrq.gov/issue/events-associated-prescribing-dispensing-and-administering-medication-
loading-doses
This article discuss…
-
psnet.ahrq.gov/node/35954/psn-pdf
August 02, 2010 - Decreasing errors in pediatric continuous intravenous
infusions.
August 2, 2010
Lehmann CU, Kim G, Gujral R, et al. Decreasing errors in pediatric continuous intravenous infusions.
Pediatr Crit Care Med. 2006;7(3):225-30.
https://psnet.ahrq.gov/issue/decreasing-errors-pediatric-continuous-intravenous-infusions
Th…
-
psnet.ahrq.gov/node/42959/psn-pdf
February 19, 2014 - A mislabeling event with batched drugs: the unintended
consequences of practice changes.
February 19, 2014
ISMP Medication Safety Alert! Acute Care Edition. 2014;19:1-3.
https://psnet.ahrq.gov/issue/mislabeling-event-batched-drugs-unintended-consequences-practice-changes
This newsletter article describes how…
-
psnet.ahrq.gov/node/40813/psn-pdf
July 19, 2017 - How to develop an effective obstetric checklist.
July 19, 2017
Fausett B, Propst A, Van Doren K, et al. How to develop an effective obstetric checklist. Am J Obstet
Gynecol. 2011;205(3):165-70. doi:10.1016/j.ajog.2011.06.003.
https://psnet.ahrq.gov/issue/how-develop-effective-obstetric-checklist
This commentary di…
-
psnet.ahrq.gov/node/42176/psn-pdf
April 17, 2013 - Checklists improve experts' diagnostic decisions.
April 17, 2013
Sibbald M, de Bruin A, van Merrienboer JJG. Checklists improve experts' diagnostic decisions. Med Educ.
2013;47(3):301-8. doi:10.1111/medu.12080.
https://psnet.ahrq.gov/issue/checklists-improve-experts-diagnostic-decisions
Checklists have recently be…
-
psnet.ahrq.gov/node/40521/psn-pdf
June 14, 2011 - Johns Hopkins receives $10 million to open patient safety
institute.
June 14, 2011
Cohn M. Baltimore Sun. May 27, 2011:A1.
https://psnet.ahrq.gov/issue/johns-hopkins-receives-10-million-open-patient-safety-institute
This newspaper article reports on plans to develop the Armstrong Institute for Patient Safety…
-
psnet.ahrq.gov/node/39693/psn-pdf
July 21, 2010 - Learning accountability for patient outcomes.
July 21, 2010
Pronovost P. Learning accountability for patient outcomes. JAMA. 2010;304(2):204-5.
doi:10.1001/jama.2010.979.
https://psnet.ahrq.gov/issue/learning-accountability-patient-outcomes
This commentary discusses efforts to reduce central line blood stream infe…
-
psnet.ahrq.gov/node/39272/psn-pdf
February 03, 2010 - Patient safety and diagnostic error: tips for your next
shift.
February 3, 2010
Sinclair D, Croskerry P. Patient safety and diagnostic error: tips for your next shift. Can Fam Physician.
2010;56(1):28-30.
https://psnet.ahrq.gov/issue/patient-safety-and-diagnostic-error-tips-your-next-shift
Through case examples, …
-
psnet.ahrq.gov/node/34621/psn-pdf
September 27, 2017 - Human Factors and Medical Devices.
September 27, 2017
Center for Devices and Radiological Health, US Food and Drug Administration.
https://psnet.ahrq.gov/issue/human-factors-and-medical-devices
Human factors engineering (HFE) helps improve human performance and reduce the risks associated with
use error. The U.S. …
-
psnet.ahrq.gov/node/36146/psn-pdf
February 05, 2019 - Guidelines for Design and Construction.
February 5, 2019
St Louis, Missouri; Facilities Guidelines Institute; 2018.
https://psnet.ahrq.gov/issue/guidelines-design-and-construction
These updated guidelines include design changes, such as the adoption of private rooms to reduce
medical error, interruptions, and hosp…