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psnet.ahrq.gov/node/72584/psn-pdf
December 16, 2020 - Hidden medication loss when using a primary
administration set for small-volume intermittent infusions.
December 16, 2020
ISMP Medication Safety Alert! Acute care edition. December 3, 2020;25(24).
https://psnet.ahrq.gov/issue/hidden-medication-loss-when-using-primary-administration-set-small-volume-
intermittent
…
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psnet.ahrq.gov/node/72750/psn-pdf
February 17, 2021 - Implementing patient and family involvement
interventions for promoting patient safety: a systematic
review and meta-analysis.
February 17, 2021
Giap T-T-T, Park M. Implementing patient and family involvement interventions for promoting patient
safety. J Patient Saf. 2021;17(2):131-140. doi:10.1097/pts.00000000000…
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psnet.ahrq.gov/node/45403/psn-pdf
September 21, 2016 - 'Superbug' scourge spreads as U.S. fails to track rising
human toll.
September 21, 2016
McNeill R, Nelson DJ, Abutaleb Y. Reuters Investigation. September 7, 2016.
https://psnet.ahrq.gov/issue/superbug-scourge-spreads-us-fails-track-rising-human-toll
Antimicrobial resistance is a pervasive threat to patient safety…
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psnet.ahrq.gov/node/47850/psn-pdf
March 27, 2019 - Medicines-related harm in the elderly post-hospital
discharge.
March 27, 2019
Cheong V-L, Tomlinson J, Khan S, et al. Prescriber. 2019;30:29-34.
https://psnet.ahrq.gov/issue/medicines-related-harm-elderly-post-hospital-discharge
Geriatric patients are particularly vulnerable to medication-related harm. This articl…
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psnet.ahrq.gov/node/846465/psn-pdf
March 22, 2023 - Difficult diagnosis in the ICU: making the right call but
beware uncertainty and bias.
March 22, 2023
Pisciotta W, Arina P, Hofmaenner D, et al. Difficult diagnosis in the ICU: making the right call but beware
uncertainty and bias. Anaesthesia. 2023;78(4):501-509. doi:10.1111/anae.15897.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/44675/psn-pdf
July 05, 2016 - Why July matters.
July 5, 2016
Petrilli CM, Del Valle J, Chopra V. Why July Matters. Acad Med. 2016;91(7):910-912.
doi:10.1097/ACM.0000000000001196.
https://psnet.ahrq.gov/issue/why-july-matters
Studies have reached conflicting conclusions about whether the "July Effect"—the belief that inpatient
mortality increa…
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psnet.ahrq.gov/node/866809/psn-pdf
September 25, 2024 - Stop the line: interventions to prevent retained surgical
items.
September 25, 2024
Angelilli S. Stop the line: interventions to prevent retained surgical items. AORN J. 2024;120(2):71-81.
doi:10.1002/aorn.14190.
https://psnet.ahrq.gov/issue/stop-line-interventions-prevent-retained-surgical-items
Retained surgica…
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psnet.ahrq.gov/node/45422/psn-pdf
October 12, 2016 - Maths anxiety and medication dosage calculation errors:
a scoping review.
October 12, 2016
Williams B, Davis S. Maths anxiety and medication dosage calculation errors: A scoping review. Nurse
Educ Pract. 2016;20:139-46. doi:10.1016/j.nepr.2016.08.005.
https://psnet.ahrq.gov/issue/maths-anxiety-and-medication-dosag…
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psnet.ahrq.gov/node/866190/psn-pdf
June 26, 2024 - What is diagnostic safety? A review of safety science
paradigms and rethinking paths to improving diagnosis.
June 26, 2024
Choi JJ. What is diagnostic safety? A review of safety science paradigms and rethinking paths to improving
diagnosis. Diagnosis (Berl). 2024;11(4):369-373. doi:10.1515/dx-2024-0008.
https://ps…
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psnet.ahrq.gov/node/46671/psn-pdf
June 25, 2018 - Twelve tips for embedding human factors and
ergonomics principles in healthcare education.
June 25, 2018
Vosper H, Hignett S, Bowie P. Twelve tips for embedding human factors and ergonomics principles in
healthcare education. Med Teach. 2017;40(4):357-363. doi:10.1080/0142159x.2017.1387240.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/42264/psn-pdf
May 25, 2022 - Safety Considerations for Container Labels and Carton
Labeling Design to Minimize Medication Errors: Guidance
for Industry.
May 25, 2022
Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for
Drug Evaluation and Research; May 18, 2022.
https://psnet.ahrq.gov/issue/safe…
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psnet.ahrq.gov/node/866966/psn-pdf
October 16, 2024 - Diagnostic Excellence in U.S. Rural Healthcare: A Call to
Action.
October 16, 2024
Ali KJ, Galvez NJ, Craig S, et al. Diagnostic Excellence In U.s. Rural Healthcare: A Call To Action.
Rockville, MD: Agency for Healthcare Research and Quality; September 2024. AHRQ Publication No. 24-
0010-9-EF
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/50776/psn-pdf
January 08, 2020 - Application of human factors to improve usability of
clinical decision support for diagnostic decision-making:
a scenario-based simulation study.
January 8, 2020
Carayon P, Hoonakker P, Hundt AS, et al. Application of human factors to improve usability of clinical
decision support for diagnostic decision-making: a…
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psnet.ahrq.gov/node/764400/psn-pdf
March 02, 2022 - A mixed methods evaluation of medication reconciliation
in the primary care setting.
March 2, 2022
Gionfriddo MR, Duboski V, Middernacht A, et al. A mixed methods evaluation of medication reconciliation
in the primary care setting. PLoS ONE. 2021;16(12):e0260882. doi:10.1371/journal.pone.0260882.
https://psnet.ahr…
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psnet.ahrq.gov/node/60007/psn-pdf
March 04, 2020 - ISMP Guidelines for Optimizing Safe Implementation and
Use of Smart Infusion Pumps.
March 4, 2020
Horsham, PA: Institute for Safe Medication Practices; 2020.
https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-implementation-and-use-smart-infusion-
pumps
Smart pumps are widely available as a medicat…
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psnet.ahrq.gov/node/50904/psn-pdf
February 19, 2020 - The harms of promoting 'Zero Harm'.
February 19, 2020
Thomas EJ. The harms of promoting ‘Zero Harm’. BMJ Qual Saf. 2019;29(1):4-6. doi:10.1136/bmjqs-2019-
009703.
https://psnet.ahrq.gov/issue/harms-promoting-zero-harm
Achieving “zero harm” has been advocated as a patient safety goal. This editorial proposes that t…
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psnet.ahrq.gov/node/50453/psn-pdf
October 09, 2019 - Effect of a sedation weaning protocol on safety and
medication use among hospitalized children post critical
illness
October 9, 2019
Solodiuk JC, Greco CD, O'Donnell KA, et al. Effect of a Sedation Weaning Protocol on Safety and
Medication Use among Hospitalized Children Post Critical Illness. J Pediatr Nurs. 2019…
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psnet.ahrq.gov/node/73871/psn-pdf
September 22, 2021 - Making Health Care Safer in Ambulatory Care Settings
and Long-term Care Facilities (R18).
September 22, 2021
Rockville, MD: Agency for Healthcare Research and Quality; September 9, 2021. PA-21-267.
https://psnet.ahrq.gov/issue/making-health-care-safer-ambulatory-care-settings-and-long-term-care-
facilities-r…
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psnet.ahrq.gov/node/61033/psn-pdf
October 14, 2020 - L.A.’s poorest patients endure long delays to see medical
specialists. Some die waiting.
October 14, 2020
Dolan J, Mejia B. Los Angeles Times. September 30, 2020.
https://psnet.ahrq.gov/issue/las-poorest-patients-endure-long-delays-see-medical-specialists-some-die-
waiting
Socioeconomic conditions influence acces…
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psnet.ahrq.gov/node/47798/psn-pdf
February 20, 2019 - Simulation safety first: an imperative.
February 20, 2019
Raemer D, Hannenberg A, Mullen A. Simulation Safety First: An Imperative. Simul Healthc.
2018;13(6):373-375. doi:10.1097/SIH.0000000000000341.
https://psnet.ahrq.gov/issue/simulation-safety-first-imperative
Although simulation training heightens the learnin…