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psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
July 01, 2012 - Integration of the dermatopathology lab into the hospital's EMR system would have reduced the probability
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psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
September 25, 2024 - CO 2 is absorbed much more rapidly and, in adults, CO 2 insufflation significantly reduced post-procedural
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psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
June 19, 2024 - The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE
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Apri…
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psnet.ahrq.gov/node/836840/psn-pdf
April 22, 2021 - The Johns Hopkins Venous Thromboembolism (VTE)
Collaborative Studies and Implements Methods to Prevent
Avoidable Cases of Hospital Associated VTE
April 7, 2022
https://psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-
implements-methods
Summary
Venous thromboembolism (…
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psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
April 24, 2024 - Patient Safety Amid Nursing Workforce Challenges
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD | April 24, 2024
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Citation Text:
Leary KB, L…
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April 24, 2024 - In Conversation with...Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT
| April 24, 2024
Also Read the Essay
View more articles from the same authors.
Citation Text:
Leary KB. In Con…
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep
January 1, 2019
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
Case Objectives
List the patient safety events that are unique to in…
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery
Citation Text:
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/node/862984/psn-pdf
February 21, 2024 - Machine learning in medication prescription: a systematic
review.
February 21, 2024
Iancu A, Leb I, Prokosch H-U, et al. Machine learning in medication prescription: a systematic review. Int J
Med Inform. 2023;180:105241. doi:10.1016/j.ijmedinf.2023.105241.
https://psnet.ahrq.gov/issue/machine-learning-medication-…
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psnet.ahrq.gov/node/838641/psn-pdf
October 19, 2022 - Optimizing Pediatric Patient Safety in the Emergency Care
Setting.
October 19, 2022
Joseph MM, Mahajan P, Snow SK, et al. Optimizing Pediatric Patient Safety in the Emergency Care
Setting. Pediatrics. 2022;150(5):e2022059673. doi:10.1542/peds.2022-059673.
https://psnet.ahrq.gov/issue/optimizing-pediatric-patient-s…
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psnet.ahrq.gov/node/60275/psn-pdf
April 29, 2020 - Misreading injectable medications—causes and
solutions: an integrative literature review.
April 29, 2020
Borradale H, Andersen P, Wallis M, et al. Misreading injectable medications—causes and solutions: an
integrative literature review. J Patient Saf. 2020. doi:10.1016/j.jcjq.2020.01.007.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/60813/psn-pdf
January 01, 2021 - Medication-related interventions delivered both in
hospital and following discharge: a systematic review and
meta-analysis.
August 19, 2020
Daliri S, Boujarfi S, el Mokaddam A, et al. Medication-related interventions delivered both in hospital and
following discharge: a systematic review and meta-analysis. BMJ Qua…
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psnet.ahrq.gov/node/845076/psn-pdf
February 22, 2023 - Advancing diagnostic equity through clinician
engagement, community partnerships, and connected
care.
February 22, 2023
Giardina TD, Woodard LCD, Singh H. Advancing diagnostic equity through clinician engagement,
community partnerships, and connected care. J Gen Intern Med. 2023;38(5):1293-1295.
doi:10.1007/s1160…
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psnet.ahrq.gov/node/46314/psn-pdf
November 01, 2020 - AHRQ Safety Program for Improving Antibiotic Use.
July 9, 2019
Agency for Healthcare Research and Quality, Johns Hopkins Medicine Armstrong Institute for Patient
Safety and Quality, and University of Chicago.
https://psnet.ahrq.gov/issue/ahrq-safety-program-improving-antibiotic-use
Improving antibiotic use is a st…
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psnet.ahrq.gov/node/48180/psn-pdf
August 21, 2019 - Burnout and Resilience and Quality and Safety Programs
in Obstetrics and Gynecology.
August 21, 2019
Main EK, Fowler JM, Gabbe SG, eds. Clin Obstet Gynecol. 2019;62:vii-xii,403-626.
https://psnet.ahrq.gov/issue/burnout-and-resilience-and-quality-and-safety-programs-obstetrics-and-
gynecology
Obstetrics is a high-…
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psnet.ahrq.gov/node/854389/psn-pdf
October 11, 2023 - Alliance for Innovation on Maternal Health: Consensus
Bundle on Sepsis in Obstetric Care.
October 11, 2023
Bauer ME, Albright C, Prabhu M, et al. Alliance for Innovation on Maternal Health: Consensus Bundle on
Sepsis in Obstetric Care. Obstet Gynecol. 2023;142(3):481-492. doi:10.1097/aog.0000000000005304.
https://…
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psnet.ahrq.gov/node/46907/psn-pdf
April 11, 2018 - To combat physician burnout and improve care, fix the
electronic health record.
April 11, 2018
Wachter R, Goldsmith J. Harv Bus Rev. March 30, 2018.
https://psnet.ahrq.gov/issue/combat-physician-burnout-and-improve-care-fix-electronic-health-record
Increased workload associated with electronic health record (EHR) …
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psnet.ahrq.gov/node/46577/psn-pdf
April 03, 2018 - The new diagnostic team.
April 3, 2018
Graber ML, Rusz D, Jones ML, et al. The new diagnostic team. Diagnosis (Berl). 2017;4(4):225-238.
doi:10.1515/dx-2017-0022.
https://psnet.ahrq.gov/issue/new-diagnostic-team
Teamwork has been highlighted as a key component of patient safety that also applies to improving
diag…
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psnet.ahrq.gov/node/47619/psn-pdf
April 08, 2019 - A decade of health information technology usability
challenges and the path forward.
April 8, 2019
Ratwani RM, Reider J, Singh H. A Decade of Health Information Technology Usability Challenges and the
Path Forward. JAMA. 2019;321(8):743-744. doi:10.1001/jama.2019.0161.
https://psnet.ahrq.gov/issue/decade-health-in…
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psnet.ahrq.gov/node/74697/psn-pdf
January 26, 2022 - The effect of medication reconciliation via a patient portal
on medication discrepancies: a randomized noninferiority
study.
January 26, 2022
Ebbens MM, Gombert-Handoko KB, Wesselink EJ, et al. The effect of medication reconciliation via a
patient portal on medication discrepancies: a randomized noninferiority stu…