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psnet.ahrq.gov/node/39715/psn-pdf
May 25, 2011 - Barriers to incident notification in a regional prehospital
setting.
May 25, 2011
Jennings PA, Stella J. Barriers to incident notification in a regional prehospital setting. Emerg Med J.
2011;28(6):526-9. doi:10.1136/emj.2010.090738.
https://psnet.ahrq.gov/issue/barriers-incident-notification-regional-prehospital-…
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psnet.ahrq.gov/node/42951/psn-pdf
September 16, 2014 - Novel approach to cardiac alarm management on
telemetry units.
September 16, 2014
Whalen DA, Covelle PM, Piepenbrink JC, et al. Novel approach to cardiac alarm management on telemetry
units. J Cardiovasc Nurs. 2014;29(5):E13-22. doi:10.1097/JCN.0000000000000114.
https://psnet.ahrq.gov/issue/novel-approach-cardiac-…
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psnet.ahrq.gov/node/41623/psn-pdf
April 05, 2013 - Preventing patient harms through systems of care.
April 5, 2013
Pronovost P, Bo-Linn GW. Preventing patient harms through systems of care. JAMA. 2012;308(8):769-70.
doi:10.1001/jama.2012.9537.
https://psnet.ahrq.gov/issue/preventing-patient-harms-through-systems-care
Recent initiatives, such as the Partnership for…
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psnet.ahrq.gov/node/42460/psn-pdf
July 31, 2013 - Effectiveness of the surgical safety checklist in a high
standard care environment.
July 31, 2013
Lübbeke A, Hovaguimian F, Wickboldt N, et al. Effectiveness of the surgical safety checklist in a high
standard care environment. Med Care. 2013;51(5):425-9. doi:10.1097/MLR.0b013e31828d1489.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/37359/psn-pdf
January 02, 2017 - Case study: preventing surgical complications at
Baystate Medical Center.
January 2, 2017
Fitzgerald J, Kanter G, Benjamin EM. Case Study: Preventing Surgical Complications at Baystate Medical
Center. The Joint Commission Journal on Quality and Patient Safety. 2016;33(11). doi:10.1016/s1553-
7250(07)33076-6.
http…
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psnet.ahrq.gov/node/46596/psn-pdf
November 01, 2017 - Infection prevention and control in pediatric ambulatory
settings.
November 1, 2017
Rathore MH, Jackson MA, AAP Committee on Infections Diseases. Pediatrics. 2017;140(5):e20172857.
https://psnet.ahrq.gov/issue/infection-prevention-and-control-pediatric-ambulatory-settings
Patient safety in the ambulatory environme…
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psnet.ahrq.gov/node/73480/psn-pdf
December 17, 2024 - Improving Patient Safety with Human Factors Methods.
December 17, 2024
Armstrong Institute for Patient Safety and Quality, Baltimore, MD. April 17-18, 2025.
https://psnet.ahrq.gov/issue/improving-patient-safety-human-factors-methods
Human factors engineering (HFE) is a primary strategy for advancing safety in healt…
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psnet.ahrq.gov/node/46494/psn-pdf
January 24, 2018 - Complications.
January 24, 2018
Anaesthesia. 2018;73(suppl 1):3-101.
https://psnet.ahrq.gov/issue/complications
Study of complications can provide insights into presurgical patient counseling, risk assessment, and
medical harm prevention. Articles in this special issue explore complications in anesthesia, includin…
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psnet.ahrq.gov/node/37595/psn-pdf
March 05, 2008 - An evaluation of medication errors—the pediatric surgical
service experience.
March 5, 2008
Engum SA, Breckler FD. An evaluation of medication errors-the pediatric surgical service experience. J
Pediatr Surg. 2008;43(2):348-52. doi:10.1016/j.jpedsurg.2007.10.042.
https://psnet.ahrq.gov/issue/evaluation-medication-…
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psnet.ahrq.gov/node/41683/psn-pdf
September 19, 2012 - Techniques to improve patient safety in hospitals: what
nurse administrators need to know.
September 19, 2012
Fagan MJ. Techniques to improve patient safety in hospitals: what nurse administrators need to know. J
Nurs Adm. 2012;42(9):426-430. doi:10.1097/NNA.0b013e3182664df5.
https://psnet.ahrq.gov/issue/technique…
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psnet.ahrq.gov/node/41083/psn-pdf
December 12, 2012 - Teams under pressure in the emergency department: an
interview study.
December 12, 2012
Flowerdew L, Brown R, Russ S, et al. Teams under pressure in the emergency department: an interview
study. Emerg Med J. 2012;29(12):e2. doi:10.1136/emermed-2011-200084.
https://psnet.ahrq.gov/issue/teams-under-pressure-emergenc…
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psnet.ahrq.gov/node/73872/psn-pdf
September 22, 2021 - Parenteral nutrition safety.
September 22, 2021
Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20.
https://psnet.ahrq.gov/issue/parenteral-nutrition-safety
Parenteral nutrition (PN) processes contain various steps that are prone to errors resulting in patient harm.
This article discusses …
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psnet.ahrq.gov/node/860400/psn-pdf
January 10, 2024 - AHA Patient Safety Initiative.
January 10, 2024
American Hospital Association.
https://psnet.ahrq.gov/issue/aha-patient-safety-initiative
Leadership at the organization and system level is crucial to gaining improvement traction and
sustainability. This initiative centers on safety culture, care inequities, and wo…
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psnet.ahrq.gov/node/40403/psn-pdf
August 25, 2011 - The quality and economic impact of disruptive behaviors
on clinical outcomes of patient care.
August 25, 2011
Rosenstein AH. The quality and economic impact of disruptive behaviors on clinical outcomes of patient
care. Am J Med Qual. 2011;26(5):372-9. doi:10.1177/1062860611400592.
https://psnet.ahrq.gov/issue/qual…
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psnet.ahrq.gov/node/36425/psn-pdf
December 22, 2010 - Patient safety in the clinical laboratory: a longitudinal
analysis of specimen identification errors.
December 22, 2010
Wagar EA, Tamashiro L, Yasin B, et al. Patient safety in the clinical laboratory: a longitudinal analysis of
specimen identification errors. Arch Pathol Lab Med. 2006;130(11):1662-1668.
https://p…
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psnet.ahrq.gov/node/45026/psn-pdf
April 19, 2016 - Managing the risks of concurrent surgeries.
April 19, 2016
Mello MM, Livingston EH. Managing the Risks of Concurrent Surgeries. JAMA. 2016;315(15):1563-4.
doi:10.1001/jama.2016.2305.
https://psnet.ahrq.gov/issue/managing-risks-concurrent-surgeries
Scheduling overlapping surgeries may improve operating room efficie…
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psnet.ahrq.gov/node/42358/psn-pdf
June 12, 2013 - CDC Grand Rounds: preventing unsafe injection practices
in the U.S. health-care system.
June 12, 2013
Prevention C for DC and. CDC grand rounds: preventing unsafe injection practices in the U.S. health-care
system. MMWR Morb Mortal Wkly Rep. 2013;62(21):423-5.
https://psnet.ahrq.gov/issue/cdc-grand-rounds-preventi…
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psnet.ahrq.gov/node/43086/psn-pdf
March 26, 2014 - International Comparisons: A Focus on Quality of Care.
March 26, 2014
Ottawa, ON: Canadian Institute for Health Information; January 23, 2014.
https://psnet.ahrq.gov/issue/international-comparisons-focus-quality-care
This report compared the quality of care in Canada with 34 other countries to identify areas in whi…
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psnet.ahrq.gov/node/46408/psn-pdf
November 29, 2017 - Eliminating vincristine administration events.
November 29, 2017
Quick Safety. October 16, 2017;(37):1-3.
https://psnet.ahrq.gov/issue/eliminating-vincristine-administration-events
Vincristine administration errors can have serious consequences. This newsletter article outlines steps to
reduce risks associated wit…
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psnet.ahrq.gov/node/47047/psn-pdf
June 06, 2018 - MedStar Health Institute for Quality and Safety.
June 6, 2018
MedStar Health. 10980 Grantchester Way, Columbia, MD 21044.
https://psnet.ahrq.gov/issue/medstar-health-institute-quality-and-safety
Health care has recognized the importance of designing systems solutions that reduce risks. Established
within MedStar H…