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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 …
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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…
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psnet.ahrq.gov/node/46322/psn-pdf
August 02, 2017 - Sophisticated digital aids could help determine what ails
you.
August 2, 2017
Maron DF. Scientific American. July 21, 2017.
https://psnet.ahrq.gov/issue/sophisticated-digital-aids-could-help-determine-what-ails-you
Clinical decision support systems are a key strategy to improve diagnostic accuracy. This magazine a…
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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…
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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…
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psnet.ahrq.gov/node/45682/psn-pdf
November 01, 2017 - Changing smart pump vendors: lessons learned.
November 1, 2017
Arthur KJ, Catlin AC, Quebe A, et al. Changing Smart Pump Vendors: Lessons Learned. Hosp Pharm.
2016;51(9):782-789.
https://psnet.ahrq.gov/issue/changing-smart-pump-vendors-lessons-learned
Changes in processes, devices, and technologies can increase ri…
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psnet.ahrq.gov/node/74128/psn-pdf
December 01, 2021 - Call to action: addressing pediatric fall safety in
ambulatory environments.
December 1, 2021
Benning S, Wolfe R, Banes M, et al. Call to action: addressing pediatric fall safety in ambulatory
environments. J Pediatr Nurs. 2021;61:372-377. doi:10.1016/j.pedn.2021.09.012.
https://psnet.ahrq.gov/issue/call-action-ad…
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psnet.ahrq.gov/node/46837/psn-pdf
March 21, 2018 - Drug shortages: effect on parenteral nutrition therapy.
March 21, 2018
Holcombe B, Mattox TW, Plogsted S. Drug Shortages: Effect on Parenteral Nutrition Therapy. Nutr Clin
Pract. 2018;33(1):53-61. doi:10.1002/ncp.10052.
https://psnet.ahrq.gov/issue/drug-shortages-effect-parenteral-nutrition-therapy
Shortages of me…
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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 …
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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…
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psnet.ahrq.gov/node/46516/psn-pdf
December 16, 2017 - The business case for investing in physician well-being.
December 16, 2017
Shanafelt TD, Goh J, Sinsky CA. The Business Case for Investing in Physician Well-being. JAMA Intern
Med. 2017;177(12):1826-1832. doi:10.1001/jamainternmed.2017.4340.
https://psnet.ahrq.gov/issue/business-case-investing-physician-well-being
…
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psnet.ahrq.gov/node/44830/psn-pdf
January 01, 2019 - Tune-in and time-out: toward surgeon-led prevention of
"never" events.
February 17, 2016
Jones N. Tune-In and Time-Out: Toward Surgeon-Led Prevention of "Never" Events. J Patient Saf.
2019;15(4):e36-e39. doi:10.1097/PTS.0000000000000259.
https://psnet.ahrq.gov/issue/tune-and-time-out-toward-surgeon-led-prevention-…
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psnet.ahrq.gov/node/44224/psn-pdf
June 10, 2015 - To be sued less, doctors should consider talking to
patients more.
June 10, 2015
Carroll AE.
https://psnet.ahrq.gov/issue/be-sued-less-doctors-should-consider-talking-patients-more
Reporting on trends associated with medical malpractice, how the same physicians tend to get sued, and
reasons patients file claims, …
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psnet.ahrq.gov/node/45204/psn-pdf
September 18, 2016 - Alternative perspectives of safety in home delivered
health care: a sequential exploratory mixed method study.
September 18, 2016
Jones S. Alternative perspectives of safety in home delivered health care: a sequential exploratory mixed
method study. J Adv Nurs. 2016;72(10):2536-46. doi:10.1111/jan.13006.
https://p…
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psnet.ahrq.gov/node/47381/psn-pdf
April 03, 2019 - The role of the patient in patient safety: what can we learn
from healthcare's history?
April 3, 2019
Leistikow I, Huisman F. The role of the patient in patient safety: What can we learn from healthcare's
history? J Patient Saf Risk Manag. 2018;23(4):139-141. doi:10.1177/2516043518791051.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/41017/psn-pdf
February 01, 2013 - Safe surgery: how accurate are we at predicting intra-
operative blood loss?
February 1, 2013
Solon JG, Egan C, McNamara DA. Safe surgery: how accurate are we at predicting intra-operative blood
loss? J Eval Clin Pract. 2013;19(1):100-5. doi:10.1111/j.1365-2753.2011.01779.x.
https://psnet.ahrq.gov/issue/safe-surge…
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psnet.ahrq.gov/node/46789/psn-pdf
March 20, 2018 - Healthcare professionals' views of smart glasses in
intensive care: a qualitative study.
March 20, 2018
Romare C, Hass U, Skär L. Healthcare professionals' views of smart glasses in intensive care: A qualitative
study. Intensive Crit Care Nurs. 2018;45:66-71. doi:10.1016/j.iccn.2017.11.006.
https://psnet.ahrq.gov/…
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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.
…
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psnet.ahrq.gov/node/45514/psn-pdf
November 02, 2016 - Building a culture of safety in ophthalmology.
November 2, 2016
Custer PL, Fitzgerald ME, Herman DC, et al. Building a Culture of Safety in Ophthalmology.
Ophthalmology. 2016;123(9 Suppl):S40-5. doi:10.1016/j.ophtha.2016.06.019.
https://psnet.ahrq.gov/issue/building-culture-safety-ophthalmology
Efforts to reduce m…
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psnet.ahrq.gov/node/34808/psn-pdf
February 18, 2011 - The high cost of low-frequency events: the anatomy and
economics of surgical mishaps.
February 18, 2011
Couch NP, Tilney NL, Rayner AA, et al. The high cost of low-frequency events: the anatomy and
economics of surgical mishaps. N Engl J Med. 1981;304(11):634-7.
https://psnet.ahrq.gov/issue/high-cost-low-frequency…