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psnet.ahrq.gov/node/47082/psn-pdf
July 02, 2019 - Effect of systematic physician cross-checking on
reducing adverse events in the emergency department:
the CHARMED cluster randomized trial.
July 2, 2019
Freund Y, Goulet H, Leblanc J, et al. Effect of Systematic Physician Cross-checking on Reducing Adverse
Events in the Emergency Department: The CHARMED Cluster Ra…
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psnet.ahrq.gov/node/48016/psn-pdf
January 01, 2020 - Reducing three infections across cardiac surgery
programs: a multisite cross-unit collaboration.
May 22, 2019
Chang BH, Hsu Y-J, Rosen MA, et al. Reducing Three Infections Across Cardiac Surgery Programs: A
Multisite Cross-Unit Collaboration. Am J Med Qual. 2020;35(1):37-45. doi:10.1177/1062860619845494.
https://p…
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psnet.ahrq.gov/node/46711/psn-pdf
July 01, 2019 - The STOP Measure. Safe and Transparent Opioid
Prescribing to Promote Patient Safety and Reduced Risk
of Opioid Misuse.
July 1, 2019
Washington, DC: America's Health Insurance Plans; 2019.
https://psnet.ahrq.gov/issue/stop-measure-safe-and-transparent-opioid-prescribing-promote-patient-safety-
and-reduced-risk
Gu…
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psnet.ahrq.gov/node/44785/psn-pdf
January 27, 2016 - Reducing Adverse Drug Events Related to Opioids
Implementation Guide.
January 27, 2016
Frederickson TW. Gordon DB, De Pinto M, et al. Philadelphia, PA: Society of Hospital Medicine; 2015.
https://psnet.ahrq.gov/issue/reducing-adverse-drug-events-related-opioids-implementation-guide
Opioids are high-risk medication…
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psnet.ahrq.gov/node/842759/psn-pdf
January 18, 2023 - Cognitive aids in the management of clinical
emergencies: a systematic review.
January 18, 2023
Greig PR, Zolger D, Onwochei DN, et al. Cognitive aids in the management of clinical emergencies: a
systematic review. Anaesthesia. 2023;78(3):343-355. doi:10.1111/anae.15939.
https://psnet.ahrq.gov/issue/cognitive-aids…
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psnet.ahrq.gov/node/46254/psn-pdf
October 09, 2017 - Using risk stratification to reduce medical errors in
cervical cancer prevention.
October 9, 2017
Perkins RB, Cain JM, Feldman S. Using Risk Stratification to Reduce Medical Errors in Cervical Cancer
Prevention. JAMA Intern Med. 2017;177(10):1411-1412. doi:10.1001/jamainternmed.2017.3999.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/73969/psn-pdf
October 26, 2021 - Important Actions Community Pharmacists Need to Take
Now to Reduce Potentially Harmful Dispensing Errors.
October 13, 2021
Institute for Safe Medication Practices. October 26, 2021.
https://psnet.ahrq.gov/issue/important-actions-community-pharmacists-need-take-now-reduce-potentially-
harmful-dispensing
Community …
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psnet.ahrq.gov/node/837211/psn-pdf
May 25, 2022 - 4 actions to reduce medical errors in U.S. hospitals.
May 25, 2022
Toussaint JS, Segel KT. Harvard Business Review. April 20, 2022.
https://psnet.ahrq.gov/issue/4-actions-reduce-medical-errors-us-hospitals
The patient safety movement has had mixed results in sustaining improvement and commitment. This
comment…
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psnet.ahrq.gov/node/840169/psn-pdf
November 16, 2022 - ISMP survey on tall man (mixed case) lettering to reduce
drug name confusion.
November 16, 2022
Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/ismp-survey-tall-man-mixed-case-lettering-reduce-drug-name-confusion
Mixed case letters are one suggested strategy to reduce look-alike medication na…
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psnet.ahrq.gov/node/47775/psn-pdf
April 03, 2019 - Reducing diagnostic errors worldwide through diagnostic
management teams.
April 3, 2019
Verna R, Velazquez AB, Laposata M. Reducing Diagnostic Errors Worldwide Through Diagnostic
Management Teams. Ann Lab Med. 2019;39(2):121-124. doi:10.3343/alm.2019.39.2.121.
https://psnet.ahrq.gov/issue/reducing-diagnostic-error…
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psnet.ahrq.gov/node/846755/psn-pdf
March 29, 2023 - Reducing diagnostic errors in the emergency department
at the time of patient treatment.
March 29, 2023
Petts A, Neep M, Thakkalpalli M. Reducing diagnostic errors in the emergency department at the time of
patient treatment. Emerg Med Australas. 2023;35(3):466-473. doi:10.1111/1742-6723.14146.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/72481/psn-pdf
November 18, 2020 - Computer-based simulation to reduce EHR-related
chemotherapy ordering errors.
November 18, 2020
Wyatt KD, Freedman EB, Arteaga GM, et al. Computer?based simulation to reduce EHR?related
chemotherapy ordering errors. Cancer Med. 2020;9(23):8844-8851. doi:10.1002/cam4.3496.
https://psnet.ahrq.gov/issue/computer-base…
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psnet.ahrq.gov/node/60628/psn-pdf
July 14, 2020 - The Power to Predict: Leveraging Medical Malpractice
Data to Reduce Patient Harm and Financial Loss.
June 24, 2020
Cambridge, MA; CRICO Strategies: July 14, 2020.
https://psnet.ahrq.gov/issue/power-predict-leveraging-medical-malpractice-data-reduce-patient-harm-and-
financial-loss
Malpractice claims can generate …
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psnet.ahrq.gov/node/866441/psn-pdf
August 07, 2024 - Association of patient photographs and reduced retract-
and-reorder events.
August 7, 2024
Rzewnicki D, Kanvinde A, Gillespie S, et al. Association of patient photographs and reduced retract-and-
reorder events. JAMIA Open. 2024;7(3):ooae042. doi:10.1093/jamiaopen/ooae042.
https://psnet.ahrq.gov/issue/association-…
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psnet.ahrq.gov/node/47297/psn-pdf
October 31, 2018 - Reducing treatment errors through point-of-care
glucometer configuration.
October 31, 2018
Estock JL, Pham I-T, Curinga HK, et al. Reducing Treatment Errors Through Point-of-Care Glucometer
Configuration. Jt Comm J Qual Patient Saf. 2018;44(11):683-694. doi:10.1016/j.jcjq.2018.03.014.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/47140/psn-pdf
May 01, 2019 - Reduced verification of medication alerts increases
prescribing errors.
May 1, 2019
Lyell D, Magrabi F, Coiera E. Reduced Verification of Medication Alerts Increases Prescribing Errors. Appl
Clin Inform. 2019;10(1):66-76. doi:10.1055/s-0038-1677009.
https://psnet.ahrq.gov/issue/reduced-verification-medication-aler…
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psnet.ahrq.gov/node/838311/psn-pdf
October 12, 2022 - How to reduce stigma and bias in clinical communication:
a narrative review.
October 12, 2022
Healy M, Richard A, Kidia K. How to reduce stigma and bias in clinical communication: a narrative review. J
Gen Intern Med. 2022;37(10):2533-2540. doi:10.1007/s11606-022-07609-y.
https://psnet.ahrq.gov/issue/how-reduce-st…
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psnet.ahrq.gov/node/35038/psn-pdf
January 02, 2017 - Using Six Sigma to reduce medication errors in a home-
delivery pharmacy service.
January 2, 2017
Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery
pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24.
https://psnet.ahrq.gov/issue/using-six-sigma-redu…
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psnet.ahrq.gov/node/44872/psn-pdf
February 12, 2016 - Reducing preventable harm in hospitals.
February 12, 2016
Bornstein D. New York Times. January 26, and February 2, 2016.
https://psnet.ahrq.gov/issue/reducing-preventable-harm-hospitals
Discussing the importance of designing safeguards to prevent system failures that can result in patient
harm, this two-part newsp…
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psnet.ahrq.gov/node/41241/psn-pdf
June 15, 2012 - Using root cause analysis to reduce falls with injury in the
psychiatric unit.
June 15, 2012
Lee A, Mills PD, Watts B. Using root cause analysis to reduce falls with injury in the psychiatric unit. Gen
Hosp Psychiatry. 2012;34(3):304-11. doi:10.1016/j.genhosppsych.2011.12.007.
https://psnet.ahrq.gov/issue/using-ro…