-
psnet.ahrq.gov/node/60766/psn-pdf
August 05, 2020 - Dermatology faces a reckoning: lack of darker skin in
textbooks and journals harms care for patients of color.
August 5, 2020
McFarling UL. Stat. July 21, 2020.
https://psnet.ahrq.gov/issue/dermatology-faces-reckoning-lack-darker-skin-textbooks-and-journals-harms-
care-patients-color
Dermatologists rely on v…
-
psnet.ahrq.gov/node/35019/psn-pdf
June 22, 2009 - Improving patient safety in critical care: big challenge,
exciting opportunity/L'amelioration de la securite des
patients a l'unite des soins intensifs : un grand defi, une
occasion stimulante.
June 22, 2009
Dodek P. Improving patient safety in critical care: big challenge, exciting opportunity. Can J Anaesth.
20…
-
psnet.ahrq.gov/node/74064/psn-pdf
May 27, 2021 - Achieving zero inequity: lessons learned from patient
safety.
May 27, 2021
Gandhi TK. NEJM Catalyst. May 27, 2021.
https://psnet.ahrq.gov/issue/achieving-zero-inequity-lessons-learned-patient-safety
The COVID-19 pandemic has shown a spotlight on bias, disparities, and inequity in the healthcare system.
The author…
-
psnet.ahrq.gov/node/43677/psn-pdf
November 19, 2014 - Reporting and Learning Systems for Medication Errors:
The Role of Pharmacovigilance Centres.
November 19, 2014
Bencheikh SR, Cousins D, Benabdallah G, et al. Geneva, Switzerland: World Health Organization; October
2014. ISBN: 9789241507943.
https://psnet.ahrq.gov/issue/reporting-and-learning-systems-medication-err…
-
psnet.ahrq.gov/node/46483/psn-pdf
October 04, 2017 - Fall Prevention in Hospitals Training Program.
October 4, 2017
Rockville, MD: Agency for Healthcare Research and Quality; 2017.
https://psnet.ahrq.gov/issue/fall-prevention-hospitals-training-program
Falls are a primary focus of quality and patient safety improvement efforts in hospitals. This training
program pro…
-
psnet.ahrq.gov/node/40188/psn-pdf
February 02, 2011 - Decreasing mislabeled laboratory specimens using
barcode technology and bedside printers.
February 2, 2011
Brown JE, Smith N, Sherfy BR. Decreasing mislabeled laboratory specimens using barcode technology
and bedside printers. J Nurs Care Qual. 2011;26(1):13-21. doi:10.1097/NCQ.0b013e3181e4e6dd.
https://psnet.ahrq…
-
psnet.ahrq.gov/node/44782/psn-pdf
January 13, 2016 - The Swiss cheese model of adverse event
occurrence—closing the holes.
January 13, 2016
Stein JE, Heiss K. The Swiss cheese model of adverse event occurrence--Closing the holes. Semin Pediatr
Surg. 2015;24(6):278-82. doi:10.1053/j.sempedsurg.2015.08.003.
https://psnet.ahrq.gov/issue/swiss-cheese-model-adverse-event…
-
psnet.ahrq.gov/node/45987/psn-pdf
April 26, 2017 - Using simulation to prepare nursing staff for the move to
a new building.
April 26, 2017
Knippa S, Senecal P-A. Using Simulation to Prepare Nursing Staff for the Move to a New Building. J
Nurses Prof Dev. 2017;33(2):E1-E5. doi:10.1097/NND.0000000000000329.
https://psnet.ahrq.gov/issue/using-simulation-prepare-nurs…
-
psnet.ahrq.gov/node/42961/psn-pdf
February 19, 2014 - Healthcare-associated infections: a national patient safety
problem and the coordinated response.
February 19, 2014
Jeeva RR, Wright D. Healthcare-associated infections: a national patient safety problem and the
coordinated response. Med Care. 2014;52(2 Suppl 1):S4-8. doi:10.1097/MLR.0b013e3182a54581.
https://psne…
-
psnet.ahrq.gov/node/41633/psn-pdf
January 01, 2013 - Determinants of success of quality improvement
collaboratives: what does the literature show?
December 31, 2012
Hulscher M, Schouten LMT, Grol R, et al. Determinants of success of quality improvement collaboratives:
what does the literature show? BMJ Qual Saf. 2013;22(1):19-31. doi:10.1136/bmjqs-2011-000651.
https…
-
psnet.ahrq.gov/node/41911/psn-pdf
December 12, 2012 - Effects of an intervention to increase bed alarm use to
prevent falls in hospitalized patients: a cluster
randomized trial.
December 12, 2012
Shorr RI, Chandler M, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in
hospitalized patients: a cluster randomized trial. Ann Intern …
-
psnet.ahrq.gov/node/50575/psn-pdf
October 23, 2019 - Dynamic pocket card for implementing ISBAR in shift
handover communication.
October 23, 2019
Schmidt T, Kocher DR, Mahendran P, et al. Dynamic Pocket Card for Implementing ISBAR in Shift
Handover Communication. Stud Health Technol Inform. 2019;267:224-229. doi:10.3233/SHTI190831.
https://psnet.ahrq.gov/issue/dynam…
-
psnet.ahrq.gov/node/46742/psn-pdf
March 14, 2018 - Evidence-based guidelines for fatigue risk management in
emergency medical services.
March 14, 2018
Patterson D, Higgins S, Van Dongen HPA, et al. Evidence-Based Guidelines for Fatigue Risk Management
in Emergency Medical Services. Prehosp Emerg Care. 2018;22(sup1):89-101.
doi:10.1080/10903127.2017.1376137.
https…
-
psnet.ahrq.gov/node/44843/psn-pdf
September 06, 2016 - Addressing the Global Shortages of Medicines, and the
Safety and Accessibility of Children's Medication.
September 6, 2016
Geneva, Switzerland: World Health Organization; 2015.
https://psnet.ahrq.gov/issue/addressing-global-shortages-medicines-and-safety-and-accessibility-childrens-
medication
Drug shortages have…
-
psnet.ahrq.gov/node/43888/psn-pdf
August 02, 2015 - Diagnostic performance by medical students working
individually or in teams.
August 2, 2015
Hautz WE, Kämmer JE, Schauber SK, et al. Diagnostic performance by medical students working
individually or in teams. JAMA. 2015;313(3):303-4. doi:10.1001/jama.2014.15770.
https://psnet.ahrq.gov/issue/diagnostic-performance…
-
psnet.ahrq.gov/node/855440/psn-pdf
November 15, 2023 - NPSD Data Spotlight: Patterns of Fall Interventions.
November 15, 2023
Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-
0055.
https://psnet.ahrq.gov/issue/npsd-data-spotlight-patterns-fall-interventions
Falls are a frequently reported sentinel event. This Data Spo…
-
psnet.ahrq.gov/node/48001/psn-pdf
May 22, 2019 - Medicines safety in anaesthetic practice.
May 22, 2019
Mackay E, Jennings J, Webber S. Medicines safety in anaesthetic practice. BJA Edu. 2019;19(5):151-157.
doi:10.1016/j.bjae.2019.01.001.
https://psnet.ahrq.gov/issue/medicines-safety-anaesthetic-practice
Human factors affect medication delivery in the operating …
-
psnet.ahrq.gov/node/74118/psn-pdf
January 01, 2022 - From HRO to HERO: making health equity a core system
capability.
November 24, 2021
Moy E, Hausmann LRM, Clancy CM. From HRO to HERO: making health equity a core system capability.
Am J Med Qual. 2022;37(1):81-83. doi:10.1097/jmq.0000000000000020.
https://psnet.ahrq.gov/issue/hro-hero-making-health-equity-core-syst…
-
psnet.ahrq.gov/node/37469/psn-pdf
January 16, 2008 - Towards the reduction of medication errors in
orthopedics and spinal surgery: outcomes using a
pharmacist-led approach.
January 16, 2008
Weiner BK, Venarske J, Yu M, et al. Towards the reduction of medication errors in orthopedics and spinal
surgery: outcomes using a pharmacist-led approach. Spine (Phila Pa 1976).…
-
psnet.ahrq.gov/node/38068/psn-pdf
March 10, 2011 - The effect of electronic prescribing on medication errors
and adverse drug events: a systematic review.
March 10, 2011
Ammenwerth E, Schnell-Inderst P, Machan C, et al. The effect of electronic prescribing on medication
errors and adverse drug events: a systematic review. J Am Med Inform Assoc. 2008;15(5):585-600.
…