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psnet.ahrq.gov/node/45625/psn-pdf
November 01, 2017 - Building comprehensive strategies for obstetric safety:
simulation drills and communication.
November 1, 2017
Austin N, Goldhaber-Fiebert SN, Daniels K, et al. Building Comprehensive Strategies for Obstetric Safety:
Simulation Drills and Communication. Anesth Analg. 2016;123(5):1181-1190.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/47270/psn-pdf
August 08, 2018 - A method to identify pediatric high-risk diagnoses missed
in the emergency department.
August 8, 2018
Sundberg M, Perron CO, Kimia A, et al. A method to identify pediatric high-risk diagnoses missed in the
emergency department. Diagnosis (Berl). 2018;5(2):63-69. doi:10.1515/dx-2018-0005.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/38070/psn-pdf
March 10, 2011 - Can surveillance systems identify and avert adverse drug
events? A prospective evaluation of a commercial
application.
March 10, 2011
Jha AK, Laguette J, Seger AC, et al. Can surveillance systems identify and avert adverse drug events? A
prospective evaluation of a commercial application. J Am Med Inform Assoc. 20…
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psnet.ahrq.gov/node/43326/psn-pdf
August 13, 2014 - Identifying high-risk medication: a systematic literature
review.
August 13, 2014
Saedder EA, Brock B, Nielsen LP, et al. Identifying high-risk medication: a systematic literature review. Eur
J Clin Pharmacol. 2014;70(6):637-45. doi:10.1007/s00228-014-1668-z.
https://psnet.ahrq.gov/issue/identifying-high-risk-medi…
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psnet.ahrq.gov/node/47593/psn-pdf
December 12, 2018 - Multi-level analysis of national nursing students'
disclosure of patient safety concerns.
December 12, 2018
Palese A, Gonella S, Grassetti L, et al. Multi-level analysis of national nursing students' disclosure of
patient safety concerns. Med Educ. 2018;52(11):1156-1166. doi:10.1111/medu.13716.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/47237/psn-pdf
January 01, 2020 - First-year analysis of the Operating Room Black Box
study.
July 25, 2018
Jung JJ, Jüni P, Lebovic G, et al. First-year Analysis of the Operating Room Black Box Study. Ann Surg.
2020;271(1):122-127. doi:10.1097/SLA.0000000000002863.
https://psnet.ahrq.gov/issue/first-year-analysis-operating-room-black-box-study
An…
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psnet.ahrq.gov/node/46390/psn-pdf
October 29, 2017 - Using data to enhance performance and improve quality
and safety in surgery.
October 29, 2017
Goldenberg MG, Jung JJ, Grantcharov T. Using Data to Enhance Performance and Improve Quality and
Safety in Surgery. JAMA Surg. 2017;152(10):972-973. doi:10.1001/jamasurg.2017.2888.
https://psnet.ahrq.gov/issue/using-data-…
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psnet.ahrq.gov/node/46383/psn-pdf
September 20, 2017 - Prescription Drug Monitoring Programs: Evolution and
Evidence.
September 20, 2017
Weiner J, Bao Y, Meisel Z. LDI/CHERISH Issue Brief. June 2017.
https://psnet.ahrq.gov/issue/prescription-drug-monitoring-programs-evolution-and-evidence
Health care has been exploring a variety of strategies to mitigate the opioid ep…
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psnet.ahrq.gov/node/34868/psn-pdf
February 03, 2011 - Role of computerized physician order entry systems in
facilitating medication errors.
February 3, 2011
Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating
medication errors. JAMA. 2005;293(10):1197-203.
https://psnet.ahrq.gov/issue/role-computerized-physician-ord…
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psnet.ahrq.gov/node/46149/psn-pdf
June 28, 2017 - Clinical outcomes associated with medication regimen
complexity in older people: a systematic review.
June 28, 2017
Wimmer BC, Cross AJ, Jokanovic N, et al. Clinical Outcomes Associated with Medication Regimen
Complexity in Older People: A Systematic Review. J Am Geriatr Soc. 2016;65(4):747-753.
doi:10.1111/jgs.14…
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psnet.ahrq.gov/node/36529/psn-pdf
August 09, 2011 - 5 Million Lives Campaign.
August 9, 2011
Institute for Healthcare Improvement; IHI
https://psnet.ahrq.gov/issue/5-million-lives-campaign
The Institute for Healthcare Improvement's 100,000 Lives Campaign successfully engaged more than
3,000 US hospitals in a coordinated effort to reduce preventable inpatient deaths…
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psnet.ahrq.gov/node/840167/psn-pdf
November 16, 2022 - 'Reading the Signals' : Maternity and Neonatal Services in
East Kent – the Report of the Independent Investigation.
November 16, 2022
Kirkup B. Department of Health and Social Care. London, England: Crown Copyright; 2022. ISBN:
9781528636759.
https://psnet.ahrq.gov/issue/reading-signals-maternity-and-neonata…
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psnet.ahrq.gov/node/43114/psn-pdf
April 09, 2014 - The ethics of empowering patients as partners in
healthcare-associated infection prevention.
April 9, 2014
Sharp D, Palmore T, Grady C. The ethics of empowering patients as partners in healthcare-associated
infection prevention. Infect Control Hosp Epidemiol. 2014;35(3):307-9. doi:10.1086/675288.
https://psnet.ahr…
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psnet.ahrq.gov/node/43692/psn-pdf
April 22, 2015 - Surgeon-specific mortality data disguise wider failings in
delivery of safe surgical services.
April 22, 2015
Westaby S, De Silva R, Petrou M, et al. Surgeon-specific mortality data disguise wider failings in delivery of
safe surgical services. Eur J Cardiothorac Surg. 2015;47(2):341-5. doi:10.1093/ejcts/ezu380.
h…
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psnet.ahrq.gov/node/843521/psn-pdf
February 01, 2023 - How providers can optimize effective and safe scribe use:
a qualitative study.
February 1, 2023
Corby S, Ash JS, Florig ST, et al. How providers can optimize effective and safe scribe use: a qualitative
study. J Gen Intern Med. 2023;38(9):2052-2058. doi:10.1007/s11606-022-07942-2.
https://psnet.ahrq.gov/issue/how-…
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psnet.ahrq.gov/node/43616/psn-pdf
October 29, 2014 - Preventing Healthcare-Associated Infections: Results and
Lessons Learned from AHRQ's HAI Program.
October 29, 2014
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Infect Control Hosp Epidemiol. 2014;35(suppl 3):S1-
S141.
https://psnet.ahrq.gov/issue/preventing-healthcare-associated-infections-results-and-lesson…
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psnet.ahrq.gov/node/47503/psn-pdf
October 24, 2018 - I-PASS checklist: a powerful tool for patient handoffs.
October 24, 2018
Peeples L. Pharmacy Practice News. October 10, 2018.
https://psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs
Structured handoffs can reduce communication problems that contribute to medical error. This magazine
article re…
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psnet.ahrq.gov/node/46100/psn-pdf
July 11, 2017 - The tension between promoting mobility and preventing
falls in the hospital.
July 11, 2017
Growdon ME, Shorr RI, Inouye SK. The Tension Between Promoting Mobility and Preventing Falls in the
Hospital. JAMA Intern Med. 2017;177(6):759-760. doi:10.1001/jamainternmed.2017.0840.
https://psnet.ahrq.gov/issue/tension-be…
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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/44183/psn-pdf
November 03, 2015 - The absence of a drug–disease interaction alert leads to a
child's death.
November 3, 2015
ISMP Medication Safety Alert! Acute Care Edition. May 21, 2015;20:1-4.
https://psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death
The disabling of alerts due to alarm fatigue can hinder the abilit…