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psnet.ahrq.gov/node/40287/psn-pdf
March 16, 2011 - The influence of 'Tall Man' lettering on errors of visual
perception in the recognition of written drug names.
March 16, 2011
Darker IT, Gerret D, Filik R, et al. The influence of 'Tall Man' lettering on errors of visual perception in the
recognition of written drug names. Ergonomics. 2011;54(1):21-33. doi:10.1080/…
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psnet.ahrq.gov/node/44990/psn-pdf
July 11, 2017 - Automatic errors: a case series on the errors inherent in
electronic prescribing.
July 11, 2017
Lourenco LM, Bursua A, Groo VL. Automatic Errors: A Case Series on the Errors Inherent in Electronic
Prescribing. J Gen Intern Med. 2016;31(7):808-811. doi:10.1007/s11606-016-3606-5.
https://psnet.ahrq.gov/issue/automat…
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psnet.ahrq.gov/node/44531/psn-pdf
September 30, 2015 - Never Events for Hospital Care in Canada: Safer Care for
Patients.
September 30, 2015
Toronto, ON: Health Quality Ontario and the Canadian Patient Safety Institute; September 2015. ISBN:
9781460666180.
https://psnet.ahrq.gov/issue/never-events-hospital-care-canada-safer-care-patients
The never events list was dev…
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psnet.ahrq.gov/node/43379/psn-pdf
August 14, 2014 - Unit of measurement used and parent medication dosing
errors.
August 14, 2014
Yin S, Dreyer BP, Ugboaja DC, et al. Unit of measurement used and parent medication dosing errors.
Pediatrics. 2014;134(2):e354-61. doi:10.1542/peds.2014-0395.
https://psnet.ahrq.gov/issue/unit-measurement-used-and-parent-medication-dosi…
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psnet.ahrq.gov/node/60192/psn-pdf
April 01, 2020 - Effective Reporting Could Improve Safe Use of Electronic
Health Records.
April 1, 2020
Philadelphia, PA: Pew Charitable Trusts; March 2020.
https://psnet.ahrq.gov/issue/effective-reporting-could-improve-safe-use-electronic-health-records
Electronic health records both enhance and challenge the safety of care proce…
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psnet.ahrq.gov/node/47925/psn-pdf
August 21, 2019 - Second victims and mindfulness: a systematic review.
August 21, 2019
S Miller C, Scott SD, Beck M. Second victims and mindfulness: a systematic review. J Patient Saf Risk
Manag. 2019;24(3):108-117. doi:10.1177/2516043519838176.
https://psnet.ahrq.gov/issue/second-victims-and-mindfulness-systematic-review
The secon…
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psnet.ahrq.gov/node/40992/psn-pdf
December 15, 2011 - Should patients get direct access to their laboratory test
results?: An answer with many questions.
December 15, 2011
Giardina TD, Singh H. Should patients get direct access to their laboratory test results? An answer with
many questions. JAMA. 2011;306(22):2502-2503. doi:10.1001/jama.2011.1797.
https://psnet.ahrq…
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psnet.ahrq.gov/node/46701/psn-pdf
December 20, 2017 - The other big drug problem: older people taking too many
pills.
December 20, 2017
Boodman SG. Washington Post. December 9, 2017.
https://psnet.ahrq.gov/issue/other-big-drug-problem-older-people-taking-too-many-pills
The prevalence of polypharmacy among older patients represents an important concern for health care…
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psnet.ahrq.gov/node/43229/psn-pdf
June 04, 2014 - Liquid medication dosing errors in children: role of
provider counseling strategies.
June 4, 2014
Yin S, Dreyer BP, Moreira HA, et al. Liquid medication dosing errors in children: role of provider counseling
strategies. Acad Pediatr. 2014;14(3):262-70. doi:10.1016/j.acap.2014.01.003.
https://psnet.ahrq.gov/issue/l…
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psnet.ahrq.gov/node/60656/psn-pdf
July 08, 2020 - COVID-19: to be or not to be; that is the diagnostic
question.
July 8, 2020
Coleman JJ, Manavi K, Marson EJ, et al. COVID-19: to be or not to be; that is the diagnostic question.
Postgrad Med J. 2020;96(1137):392-398. doi:10.1136/postgradmedj-2020-137979.
https://psnet.ahrq.gov/issue/covid-19-be-or-not-be-diagnost…
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psnet.ahrq.gov/node/43234/psn-pdf
June 04, 2014 - Independent double-checks for high-alert medications:
essential practice.
June 4, 2014
Baldwin K, Walsh V. Independent double-checks for high-alert medications: essential practice. Nursing
(Brux). 2014;44(4):65-7. doi:10.1097/01.NURSE.0000444547.64972.dc.
https://psnet.ahrq.gov/issue/independent-double-checks-high…
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psnet.ahrq.gov/node/60742/psn-pdf
July 29, 2020 - Doctors and dentists still flooding U.S. with opioid
prescriptions.
July 29, 2020
Mann B. Doctors and dentists still flooding U.S. with opioid prescriptions. National Public Radio. 2020;July
17.
https://psnet.ahrq.gov/issue/doctors-and-dentists-still-flooding-us-opioid-prescriptions
Despite efforts to reduce opio…
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psnet.ahrq.gov/node/865493/psn-pdf
April 03, 2024 - Implement strategies to prevent persistent medication
errors and hazards: 2024.
April 3, 2024
ISMP Medication Safety Alert! Acute Care. 2024;29(6):1-4.
https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards-2024
Systemic failures can perpetuate unsafe care if a lack of p…
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psnet.ahrq.gov/node/44260/psn-pdf
November 06, 2015 - Innovative teaching in situational awareness.
November 6, 2015
Gregory A, Hogg G, Ker J. Innovative teaching in situational awareness. Clin Teach. 2015;12(5):331-5.
doi:10.1111/tct.12310.
https://psnet.ahrq.gov/issue/innovative-teaching-situational-awareness
Nontechnical skills contribute to successful teamwork an…
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psnet.ahrq.gov/node/36576/psn-pdf
January 14, 2011 - Need for standardized sign-out in the emergency
department: a survey of emergency medicine residency
and pediatric emergency medicine fellowship program
directors.
January 14, 2011
Sinha M, Shriki J, Salness R, et al. Need for standardized sign-out in the emergency department: a survey
of emergency medicine resid…
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psnet.ahrq.gov/node/44944/psn-pdf
July 01, 2016 - Managing and mitigating conflict in healthcare teams: an
integrative review.
July 1, 2016
Almost J, Wolff AC, Stewart-Pyne A, et al. Managing and mitigating conflict in healthcare teams: an
integrative review. J Adv Nurs. 2016;72(7):1490-505. doi:10.1111/jan.12903.
https://psnet.ahrq.gov/issue/managing-and-mitigat…
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psnet.ahrq.gov/node/38276/psn-pdf
December 10, 2008 - Addressing delays in medication administration for
patients transferred from the hospital to the nursing
home: a pilot quality improvement project.
December 10, 2008
Ward KT, Bates-Jensen B, Eslami MS, et al. Addressing delays in medication administration for patients
transferred from the hospital to the nursing h…
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psnet.ahrq.gov/node/50594/psn-pdf
October 30, 2019 - Pharmacist linkage in care transitions: from academic
medical center to community.
October 30, 2019
Bloodworth LS, Malinowski SS, Lirette ST, et al. Pharmacist linkage in care transitions: from academic
medical center to community. J Am Pharm Assoc . 2019;59(6):896-904. doi:10.1016/j.japh.2019.08.011.
https://psne…
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psnet.ahrq.gov/node/50825/psn-pdf
January 22, 2020 - Investigation into Detection of Retained Vaginal Swabs
and Tampons Following Childbirth.
January 22, 2020
Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.
https://psnet.ahrq.gov/issue/investigation-detection-retained-vaginal-swabs-and-tampons-following-
childbirth
Maternal care during a…
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psnet.ahrq.gov/node/73477/psn-pdf
July 07, 2021 - Closing Death’s Door: Legal Innovations to End the
Epidemic of Healthcare Harm.
July 7, 2021
Saks M, Landsman S. New York, NY: Oxford University Press; 2021. ISBN: 9780190667986.
https://psnet.ahrq.gov/issue/closing-deaths-door-legal-innovations-end-epidemic-healthcare-harm
A weave of systemic factors c…