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psnet.ahrq.gov/node/47367/psn-pdf
October 15, 2018 - Themed Issue on Innovations in Medication Safety.
October 15, 2018
Kane-Gill SL. Innovations in Medication Safety: Services and Technologies to Enhance the Understanding
and Prevention of Adverse Drug Reactions. Pharmacotherapy. 2018;38(8):782-784.
doi:10.1002/phar.2154.
https://psnet.ahrq.gov/issue/themed-issue-i…
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psnet.ahrq.gov/node/47279/psn-pdf
July 23, 2018 - No Place Like Home: Advancing the Safety of Care in the
Home.
July 23, 2018
Boston, MA: Institute for Healthcare Improvement; 2018.
https://psnet.ahrq.gov/issue/no-place-home-advancing-safety-care-home
The home care setting harbors unique challenges to patient safety. This report builds on a previous
evidence ass…
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psnet.ahrq.gov/node/46861/psn-pdf
February 28, 2018 - Special K with no license to kill: accidental ketamine
overdose on induction of general anesthesia.
February 28, 2018
Warner LL, Smischney N. Accidental Ketamine Overdose on Induction of General Anesthesia. Am J Case
Rep. 2018;19:10-12.
https://psnet.ahrq.gov/issue/special-k-no-license-kill-accidental-ketamine-ove…
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psnet.ahrq.gov/node/44664/psn-pdf
May 30, 2016 - Ventilator-related adverse events: a taxonomy and
findings from 3 incident reporting systems.
May 30, 2016
Pham JC, Williams TL, Sparnon EM, et al. Ventilator-Related Adverse Events: A Taxonomy and Findings
From 3 Incident Reporting Systems. Respir Care. 2016;61(5):621-31. doi:10.4187/respcare.04151.
https://psnet…
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psnet.ahrq.gov/node/47924/psn-pdf
June 05, 2019 - Effect of a central call center on employee perceptions of
safety culture within community pharmacies in an
academic health system.
June 5, 2019
Bowden A, Mullin S, Tak C, et al. Effect of a central call center on employee perceptions of safety culture
within community pharmacies in an academic health system. Am J…
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psnet.ahrq.gov/node/44422/psn-pdf
November 17, 2017 - Stop the noise: a quality improvement project to decrease
electrocardiographic nuisance alarms.
November 17, 2017
Sendelbach S, Wahl S, Anthony A, et al. Stop the Noise: A Quality Improvement Project to Decrease
Electrocardiographic Nuisance Alarms. Crit Care Nurse. 2015;35(4):15-22; quiz 1p following 22.
doi:10.4…
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psnet.ahrq.gov/node/44536/psn-pdf
November 11, 2015 - Healthcare system intervention for safer use of medicines
in elderly patients in primary care—a qualitative study of
the participants' perceptions of self-assessment, peer
review, feedback and agreement for change.
November 11, 2015
Lenander C, Bondesson Å, Midlöv P, et al. Healthcare system intervention for safer…
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psnet.ahrq.gov/innovations
February 26, 2025 - Innovations
The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …
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psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
September 15, 2024 - COVID-19: Team and Human Factors to Improve Safety
Citation Text:
Zipperer L. COVID-19: Team and Human Factors to Improve Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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Format:
Google Scholar…
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psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
December 15, 2024 - Deprescribing as a Patient Safety Strategy
Citation Text:
Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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Format:
Google Scholar BibTeX …
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psnet.ahrq.gov/node/845652/psn-pdf
March 14, 2023 - Controlled substance drug diversion by healthcare
workers as a threat to patient safety.
March 14, 2023
ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4):1-4; March 9, 2023:28(5):1-4.
https://psnet.ahrq.gov/issue/controlled-substance-drug-diversion-healthcare-workers-threat-patient-safety
D…
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psnet.ahrq.gov/node/73471/psn-pdf
July 07, 2021 - Rapid response teams as a patient safety practice for
failure to rescue.
July 7, 2021
Fischer CP, Bilimoria KY, Ghaferi AA. Rapid Response Teams as a Patient Safety Practice for Failure to
Rescue. JAMA. 2021;326(2):179-180. doi:10.1001/jama.2021.7510.
https://psnet.ahrq.gov/issue/rapid-response-teams-patient-safet…
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psnet.ahrq.gov/node/47331/psn-pdf
October 17, 2018 - Description and factors associated with missed nursing
care in an acute care community hospital.
October 17, 2018
Duffy JR, Culp S, Padrutt T. Description and factors associated with missed nursing care in an acute care
community hospital. J Nurs Adm. 2018;48(7-8):361-367. doi:10.1097/NNA.0000000000000630.
https:/…
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psnet.ahrq.gov/node/851065/psn-pdf
June 28, 2023 - Patient safety of perioperative medication through the
lens of digital health and artificial intelligence.
June 28, 2023
Ye J. Patient safety of perioperative medication through the lens of digital health and artificial intelligence.
JMIR Periop Med. 2023;6:e34453. doi:10.2196/34453.
https://psnet.ahrq.gov/issue/p…
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psnet.ahrq.gov/node/47148/psn-pdf
June 25, 2018 - Necessity for a pathway for "high-alert" patients.
June 25, 2018
Shane R, Amer K, Noh L, et al. Necessity for a pathway for "high-alert" patients. Am J Health Syst Pharm.
2018;75(13):993-997. doi:10.2146/ajhp170397.
https://psnet.ahrq.gov/issue/necessity-pathway-high-alert-patients
Medication errors can contribute…
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psnet.ahrq.gov/node/838081/psn-pdf
September 14, 2022 - Medication dosage calculation among nursing students:
does digital technology make a difference? A literature
review.
September 14, 2022
Stake-Nilsson K, Almstedt M, Fransson G, et al. Medication dosage calculation among nursing students:
does digital technology make a difference? A literature review. BMC Nurs. 20…
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psnet.ahrq.gov/node/45650/psn-pdf
December 14, 2016 - Are physicians safely prescribing opioids for chronic
noncancer pain? A systematic review of current evidence.
December 14, 2016
Tournebize J, Gibaja V, Muszczak A, et al. Are Physicians Safely Prescribing Opioids for Chronic
Noncancer Pain? A Systematic Review of Current Evidence. Pain Pract. 2016;16(3):370-83.
d…
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psnet.ahrq.gov/node/73566/psn-pdf
August 04, 2021 - Personal formularies of primary care physicians across 4
health care systems.
August 4, 2021
Galanter W, Eguale T, Gellad WF, et al. Personal formularies of primary care physicians across 4 health
care systems. JAMA Netw Open. 2021;4(7):e2117038. doi:10.1001/jamanetworkopen.2021.17038.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/47783/psn-pdf
April 10, 2019 - An IDEA: safety training to improve critical thinking by
individuals and teams.
April 10, 2019
Browne AM, Deutsch ES, Corwin K, et al. An IDEA: Safety Training to Improve Critical Thinking by
Individuals and Teams. Am J Med Qual. 2019;34(6):569-576. doi:10.1177/1062860618820687.
https://psnet.ahrq.gov/issue/idea-s…
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psnet.ahrq.gov/node/47542/psn-pdf
January 16, 2019 - Utilizing a Systems and Design Thinking Approach for
Improving Well-Being Within Health Professional
Education and Health Care.
January 16, 2019
Kreitzer MJ, Carter K, Coffey DS, et al. NAM Perspectives. Washington, DC: National Academy of
Medicine; 2019.
https://psnet.ahrq.gov/issue/utilizing-systems-and-design-…