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psnet.ahrq.gov/node/72674/psn-pdf
January 27, 2021 - The effect of blue-enriched lighting on medical error rate
in a university hospital ICU.
January 27, 2021
Chen Y, Broman AT, Priest G, et al. The Effect of Blue-Enriched Lighting on Medical Error Rate in a
University Hospital ICU. Jt Comm J Qual Saf. 2021;47(3):165-175. doi:10.1016/j.jcjq.2020.11.007.
https://psne…
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psnet.ahrq.gov/node/72761/psn-pdf
February 17, 2021 - Using ventilator splitters during the COVID-19 pandemic--
letter to health care providers.
February 17, 2021
Silver Spring, MD: Division of Industry and Consumer Education, US Food and Drug Administration;
February 9. 2021.
https://psnet.ahrq.gov/issue/using-ventilator-splitters-during-covid-19-pandemic-letter-hea…
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psnet.ahrq.gov/node/47028/psn-pdf
May 02, 2018 - Medication errors 2018: the year in review.
May 2, 2018
Valentine D, Ingram V, Fobi BNN, Brahmbhatt V. Pharmacy Practice News. April 4, 2018.
https://psnet.ahrq.gov/issue/medication-errors-2018-year-review
Despite considerable effort, medication errors continue to occur and result in patient harm. Summari…
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psnet.ahrq.gov/node/44333/psn-pdf
July 15, 2015 - One hospital's initiatives to encourage safe opioid use.
July 15, 2015
Surprise JK, Simpson MH. One Hospital's Initiatives to Encourage Safe Opioid Use. J Infus Nurs.
2015;38(4):278-83. doi:10.1097/NAN.0000000000000110.
https://psnet.ahrq.gov/issue/one-hospitals-initiatives-encourage-safe-opioid-use
This commentar…
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psnet.ahrq.gov/node/45387/psn-pdf
August 15, 2016 - Preventing medication errors.
August 15, 2016
Stefanacci RG, Riddle A. Preventing medication errors. Geriatr Nurs. 2016;37(4):307-10.
doi:10.1016/j.gerinurse.2016.06.005.
https://psnet.ahrq.gov/issue/preventing-medication-errors
Nursing home patients are particularly vulnerable to medication errors. This commentar…
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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).…
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psnet.ahrq.gov/node/41721/psn-pdf
October 03, 2012 - Rural inpatient telepharmacy consultation demonstration
for after-hours medication review.
October 3, 2012
Cole SL, Grubbs JH, Din C, et al. Rural inpatient telepharmacy consultation demonstration for after-hours
medication review. Telemed J E Health. 2012;18(7):530-7. doi:10.1089/tmj.2011.0222.
https://psnet.ahrq…
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psnet.ahrq.gov/node/41577/psn-pdf
September 27, 2016 - Nursing perception of the impact of medication carts on
patient safety and ergonomics in a teaching health care
center.
September 27, 2016
Rochais E, Atkinson S, Bussières J-F. Nursing perception of the impact of medication carts on patient
safety and ergonomics in a teaching health care center. J Pharm Pract. 201…
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psnet.ahrq.gov/node/60263/psn-pdf
April 22, 2020 - Rationing protective gear means checking on coronavirus
patients less often. This can be deadly.
April 22, 2020
Kaplan J, Presser L, Miller M. ProPublica. April 10, 2020.
https://psnet.ahrq.gov/issue/rationing-protective-gear-means-checking-coronavirus-patients-less-often-can-
be-deadly
Increased complexity and p…
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psnet.ahrq.gov/node/43321/psn-pdf
August 02, 2015 - Costs associated with surgical site infections in Veterans
Affairs hospitals.
August 2, 2015
Schweizer ML, Cullen JJ, Perencevich E, et al. Costs Associated With Surgical Site Infections in Veterans
Affairs Hospitals. JAMA Surg. 2014;149(6):575-81. doi:10.1001/jamasurg.2013.4663.
https://psnet.ahrq.gov/issue/costs…
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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…
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psnet.ahrq.gov/node/44838/psn-pdf
February 10, 2016 - ADVERSE drug events: incidence and risk reduction
across the care continuum.
February 10, 2016
Wanderer JP, Rathmell JP. ADVERSE Drug Events: Incidence & risk reduction across the care continuum.
Anesthesiology. 2016;124(1):A23. doi:10.1097/01.anes.0000473722.20007.03.
https://psnet.ahrq.gov/issue/adverse-drug-eve…
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psnet.ahrq.gov/node/45986/psn-pdf
March 29, 2017 - Pediatric prehospital medication dosing errors: a national
survey of paramedics.
March 29, 2017
Hoyle JD, Crowe RP, Bentley MA, et al. Pediatric prehospital medication dosing errors: a national survey of
paramedics. Prehosp Emerg Care. 2017;21(2):185-191. doi:10.1080/10903127.2016.1227001.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/34870/psn-pdf
April 18, 2016 - Unintended medication discrepancies at the time of
hospital admission.
April 18, 2016
Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital
admission. Arch Intern Med. 2005;165(4):424-9.
https://psnet.ahrq.gov/issue/unintended-medication-discrepancies-time-hospita…
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psnet.ahrq.gov/node/44048/psn-pdf
November 20, 2015 - Clinical handover of the critically ill postoperative patient:
an integrative review.
November 20, 2015
Gardiner TM, Marshall AP, Gillespie BM. Clinical handover of the critically ill postoperative patient: an
integrative review. Aust Crit Care. 2015;28(4):226-34. doi:10.1016/j.aucc.2015.02.001.
https://psnet.ahrq…
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psnet.ahrq.gov/node/764411/psn-pdf
March 02, 2022 - Nowhere is safe: record number of patients contracted
Covid in the hospital in January.
March 2, 2022
Levy R, Vestal AJ. Politico. February 19, 2022.
https://psnet.ahrq.gov/issue/nowhere-safe-record-number-patients-contracted-covid-hospital-january
Transmission of COVID-19 in the health care setting continues to b…
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psnet.ahrq.gov/node/50425/psn-pdf
September 04, 2019 - Why doctors still offer treatments that may not help.
September 4, 2019
Frakt A. New York Times. August 26, 2019.
https://psnet.ahrq.gov/issue/why-doctors-still-offer-treatments-may-not-help
The slow adoption of improvement innovations is a persistent challenge to high-quality and safe patient
care. This newspaper…
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psnet.ahrq.gov/node/45658/psn-pdf
November 09, 2016 - Hospitals installed more sinks to stop infections. The
sinks can make the problem worse.
November 9, 2016
Branswell H. STAT. October 25, 2016.
https://psnet.ahrq.gov/issue/hospitals-installed-more-sinks-stop-infections-sinks-can-make-problem-worse
Hospitals have sought to improve hand hygiene with interventions su…
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psnet.ahrq.gov/node/60750/psn-pdf
August 06, 2020 - Missed breast cancer: effects of subconscious bias and
lesion characteristics.
August 6, 2020
Lamb LR, Mohallem Fonseca M, Verma R, et al. Missed breast cancer: effects of subconscious bias and
lesion characteristics. RadioGraphics. 2020;40(4):941-960. doi:10.1148/rg.2020190090.
https://psnet.ahrq.gov/issue/missed…
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psnet.ahrq.gov/node/854252/psn-pdf
October 04, 2023 - Standardization and visualization of the surgical time-out.
October 4, 2023
Levy BE, Wilt WS, Lantz S, et al. Standardization and visualization of the surgical time-out. J Patient Saf.
2023;19(7):453-459. doi:10.1097/pts.0000000000001156.
https://psnet.ahrq.gov/issue/standardization-and-visualization-surgical-time-…