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psnet.ahrq.gov/node/73253/psn-pdf
May 12, 2021 - Any new process poses a risk for errors: learning from 4
months of Coronavirus disease 2019 (COVID-19)
vaccinations.
May 12, 2021
ISMP Medication Safety Alert! Acute Care Edition. April 22, 2021.26(8):1-5.
https://psnet.ahrq.gov/issue/any-new-process-poses-risk-errors-learning-4-months-coronavirus-disease-
2019-c…
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psnet.ahrq.gov/node/39860/psn-pdf
September 01, 2017 - Interventions to improve hand hygiene compliance in
patient care.
September 1, 2017
Gould DJ, Moralejo D, Drey N, et al. Interventions to improve hand hygiene compliance in patient care.
Cochrane Database Syst Rev. 2017;9(9):CD005186. doi:10.1002/14651858.cd005186.pub4.
https://psnet.ahrq.gov/issue/interventions-i…
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psnet.ahrq.gov/node/44172/psn-pdf
September 28, 2016 - Preventing high-alert medication errors in hospital
patients.
September 28, 2016
Anderson P, Townsend T. Am Nurse Today. May 2015;10:18-23.
https://psnet.ahrq.gov/issue/preventing-high-alert-medication-errors-hospital-patients
High-alert medications have the potential to cause serious patient harm. This article fo…
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psnet.ahrq.gov/node/837206/psn-pdf
May 25, 2022 - Automated dispensing cabinet overrides-an evaluation of
necessity in a pediatric emergency department.
May 25, 2022
Paterson EP, Manning KB, Schmidt MD, et al. Automated dispensing cabinet overrides-an evaluation of
necessity in a pediatric emergency department. J Emerg Nurs. 2022;48(3):319-327.
doi:10.1016/j.jen.…
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psnet.ahrq.gov/node/851067/psn-pdf
June 28, 2023 - Assessing medication safety in settings not designated
solely for pediatric patients.
June 28, 2023
ISMP Medication Safety Alert! Acute care edition. June 15, 2023;28(12);1-5.
https://psnet.ahrq.gov/issue/assessing-medication-safety-settings-not-designated-solely-pediatric-patients
Pediatric patients are at increa…
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psnet.ahrq.gov/node/841155/psn-pdf
February 02, 2020 - Understanding unwarranted variation in clinical practice:
a focus on network effects, reflective medicine and
learning health systems.
February 2, 2020
Atsma F, Elwyn G, Westert GP. Understanding unwarranted variation in clinical practice: a focus on
network effects, reflective medicine and learning health systems…
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psnet.ahrq.gov/node/43606/psn-pdf
October 15, 2014 - Opioids for chronic noncancer pain: a position paper of
the American Academy of Neurology.
October 15, 2014
Franklin GM, Neurology AA of. Opioids for chronic noncancer pain: a position paper of the American
Academy of Neurology. Neurology. 2014;83(14):1277-84. doi:10.1212/WNL.0000000000000839.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/836758/psn-pdf
March 16, 2022 - Internet of things in healthcare for patient safety: an
empirical study.
March 16, 2022
Yesmin T, Carter MW, Gladman AS. Internet of things in healthcare for patient safety: an empirical study.
BMC Health Serv Res. 2022;22(1):278. doi:10.1186/s12913-022-07620-3.
https://psnet.ahrq.gov/issue/internet-things-healthc…
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psnet.ahrq.gov/node/860733/psn-pdf
January 17, 2024 - Staff warned about the lack of psychiatric care at a VA
clinic. They couldn’t prevent tragedy.
January 17, 2024
McGrory K, Bedi N. ProPublica, January 6, 2024.
https://psnet.ahrq.gov/issue/staff-warned-about-lack-psychiatric-care-va-clinic-they-couldnt-prevent-tragedy
Stories of mental health system failure provid…
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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/45331/psn-pdf
August 03, 2016 - Health information technologies: from hazardous to the
dark side.
August 3, 2016
Saunders C, Rutkowski AF, Pluyter J, et al. Health information technologies: From hazardous to the dark
side. J Assoc Inf Sci Technol. 2016;67(7). doi:10.1002/asi.23671.
https://psnet.ahrq.gov/issue/health-information-technologies-haz…
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psnet.ahrq.gov/node/43986/psn-pdf
September 26, 2016 - The effect of a safe zone on nurse interruptions,
distractions, and medication administration errors.
September 26, 2016
Yoder M, Schadewald D, Dietrich K. The effect of a safe zone on nurse interruptions, distractions, and
medication administration errors. J Infus Nurs. 2015;38(2):140-51. doi:10.1097/NAN.000000000…
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psnet.ahrq.gov/node/44317/psn-pdf
August 19, 2015 - Use of in-situ simulation to investigate latent safety
threats prior to opening a new emergency department.
August 19, 2015
Medwid K, Smith SW, Gang M. Use of in-situ simulation to investigate latent safety threats prior to opening
a new emergency department. Safety Sci. 2015;77:19-24. doi:10.1016/j.ssci.2015.03.01…
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psnet.ahrq.gov/node/50829/psn-pdf
January 22, 2020 - How one medical checkup can snowball into a ‘cascade’
of tests, causing more harm than good.
January 22, 2020
Ganguli I. Washington Post. January 5, 2020.
https://psnet.ahrq.gov/issue/how-one-medical-checkup-can-snowball-cascade-tests-causing-more-harm-
good
Overdiagnosis and uncertainty can result in a range of …
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psnet.ahrq.gov/node/50744/psn-pdf
December 18, 2019 - EMS crews brought patients to the hospital with
misplaced breathing tubes. None of them survived
December 18, 2019
Arditi L. Peoples Public Radio. December 3, 2019.
https://psnet.ahrq.gov/issue/ems-crews-brought-patients-hospital-misplaced-breathing-tubes-none-them-
survived
Emergency medical services are often p…
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psnet.ahrq.gov/node/837340/psn-pdf
June 08, 2022 - Wellbeing, burnout, and safe practice among healthcare
professionals: predictive influences of mindfulness,
values, and self-compassion.
June 8, 2022
Prudenzi A, D. Graham C, Flaxman PE, et al. Wellbeing, burnout, and safe practice among healthcare
professionals: predictive influences of mindfulness, values, and s…
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psnet.ahrq.gov/node/60286/psn-pdf
April 29, 2020 - With Covid-19 delaying routine care, chronic disease
startups brace for a slew of complications.
April 29, 2020
Brodwin E. STAT. April 14, 2020.
https://psnet.ahrq.gov/issue/covid-19-delaying-routine-care-chronic-disease-startups-brace-slew-
complications
Patients with cancer and other chronic disorder treatment …
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psnet.ahrq.gov/node/42673/psn-pdf
October 30, 2013 - Clinical evaluation of the ADE scorecards as a decision
support tool for adverse drug event analysis and
medication safety management.
October 30, 2013
Hackl WO, Ammenwerth E, Marcilly R, et al. Clinical evaluation of the ADE scorecards as a decision
support tool for adverse drug event analysis and medication safe…
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psnet.ahrq.gov/node/43105/psn-pdf
April 02, 2014 - Application of surgical safety standards to robotic
surgery: five principles of ethics for nonmaleficence.
April 2, 2014
Larson JA, Johnson MH, Bhayani SB. Application of surgical safety standards to robotic surgery: five
principles of ethics for nonmaleficence. J Am Coll Surg. 2014;218(2):290-3.
doi:10.1016/j.jam…
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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
…