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psnet.ahrq.gov/node/836754/psn-pdf
March 16, 2022 - State of science: evolving perspectives on ‘human error’.
March 16, 2022
Read GJM, Shorrock S, Walker GH, et al. State of science: evolving perspectives on ‘human error’.
Ergonomics. 2021;64(9):1091-1114. doi:10.1080/00140139.2021.1953615.
https://psnet.ahrq.gov/issue/state-science-evolving-perspectives-human-error…
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psnet.ahrq.gov/node/44673/psn-pdf
April 15, 2016 - The safety of emergency medicine.
April 15, 2016
Ramlakhan S, Qayyum H, Burke D, et al. The safety of emergency medicine. Emerg Med J.
2016;33(4):293-9. doi:10.1136/emermed-2014-204564.
https://psnet.ahrq.gov/issue/safety-emergency-medicine
Emergency medicine is considered a high-risk environment, but little resea…
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psnet.ahrq.gov/node/43036/psn-pdf
March 27, 2014 - Redesigning hospital alarms for patient safety: alarmed
and potentially dangerous.
March 27, 2014
Chopra V, McMahon LF. Redesigning hospital alarms for patient safety: alarmed and potentially
dangerous. JAMA. 2014;311(12):1199-200. doi:10.1001/jama.2014.710.
https://psnet.ahrq.gov/issue/redesigning-hospital-alarms…
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psnet.ahrq.gov/node/42218/psn-pdf
June 10, 2018 - Your high-alert medication list—relatively useless without
associated risk-reduction strategies.
June 10, 2018
ISMP Medication Safety Alert! Acute Care Edition. April 4, 2013;18:1-5.
https://psnet.ahrq.gov/issue/your-high-alert-medication-list-relatively-useless-without-associated-risk-
reduction
This newsletter …
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psnet.ahrq.gov/node/38705/psn-pdf
June 17, 2009 - Ambulance stretcher adverse events.
June 17, 2009
Wang HE, Weaver MD, Abo BN, et al. Ambulance stretcher adverse events. Qual Saf Health Care.
2009;18(3):213-216. doi:10.1136/qshc.2007.024562.
https://psnet.ahrq.gov/issue/ambulance-stretcher-adverse-events
This study analyzed more than 670 reported adverse events …
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psnet.ahrq.gov/node/34788/psn-pdf
March 28, 2005 - Cost of medication-related problems at a university
hospital.
March 28, 2005
Schneider PJ; Gift MG; Lee YP; Rothermich EA; Sill BE
https://psnet.ahrq.gov/issue/cost-medication-related-problems-university-hospital
This study used retrospective chart review to determine estimated costs of defined medication-related
…
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psnet.ahrq.gov/node/48166/psn-pdf
August 28, 2019 - Doctors can change opioid prescribing habits, but
progress comes in small doses.
August 28, 2019
Appleby J; Lucas E.
https://psnet.ahrq.gov/issue/doctors-can-change-opioid-prescribing-habits-progress-comes-small-doses
Efforts to reduce misuse of prescription opioids must draw from public health and behavioral stra…
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psnet.ahrq.gov/node/867645/psn-pdf
July 01, 2022 - A call to action for anticoagulation stewardship.
July 1, 2022
Burnett AE, Barnes GD. A call to action for anticoagulation stewardship. Res Pract Thromb Haemost.
2022;6(5):e12757. doi:10.1002/rth2.12757.
https://psnet.ahrq.gov/issue/call-action-anticoagulation-stewardship
Anticoagulants are high-risk medications d…
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psnet.ahrq.gov/node/44576/psn-pdf
January 23, 2018 - Healthcare Quality and Patient Safety Award.
January 23, 2018
Iowa Healthcare Collaborative.
https://psnet.ahrq.gov/issue/healthcare-quality-and-patient-safety-award
This award seeks to recognize health care organizations and professionals that have exhibited leadership
and innovation in improving patient safety i…
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psnet.ahrq.gov/node/35115/psn-pdf
April 06, 2011 - Factors predictive of intravenous fluid administration
errors in Australian surgical care wards.
April 6, 2011
Han PY, Coombes ID, Green B. Factors predictive of intravenous fluid administration errors in Australian
surgical care wards. Qual Saf Health Care. 2005;14(3):179-84.
https://psnet.ahrq.gov/issue/factors-…
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psnet.ahrq.gov/node/46661/psn-pdf
January 26, 2018 - Burnout syndrome among healthcare professionals.
January 26, 2018
Bridgeman PJ, Bridgeman MB, Barone J. Burnout syndrome among healthcare professionals. Am J Health
Syst Pharm. 2018;75(3):147-152. doi:10.2146/ajhp170460.
https://psnet.ahrq.gov/issue/burnout-syndrome-among-healthcare-professionals
Burnout affects t…
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psnet.ahrq.gov/node/42020/psn-pdf
July 16, 2013 - Effects of the implementation of a preventive
interventions program on the reduction of medication
errors in critically ill adult patients.
July 16, 2013
Romero CM, Salazar N, Rojas L, et al. Effects of the implementation of a preventive interventions program
on the reduction of medication errors in critically ill…
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psnet.ahrq.gov/node/41514/psn-pdf
July 02, 2014 - Perspective: beyond counting hours: the importance of
supervision, professionalism, transitions of care, and
workload in residency training.
July 2, 2014
Schumacher D, Slovin SR, Riebschleger MP, et al. Perspective. Academic Medicine. 2012;87(7).
doi:10.1097/acm.0b013e318257d57d.
https://psnet.ahrq.gov/issue/pers…
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psnet.ahrq.gov/node/837958/psn-pdf
December 01, 2021 - EMS Perils from Hospital Overcrowding
August 31, 2022
Brown S, Rose JS, Barnes DK. EMS Perils from Hospital Overcrowding. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
The Case
A 71-year-old man with a history of postoperative septic knee arthritis (status: post-intravenous…
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psnet.ahrq.gov/node/73606/psn-pdf
August 18, 2021 - Broadening the concept of patient safety culture through
value-based healthcare.
August 18, 2021
Dombrádi V, Bíró K, Jonitz G, et al. Broadening the concept of patient safety culture through value-based
healthcare. J Health Organ Manag. 2021;35(5):541-549. doi:10.1108/jhom-07-2020-0287.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/73971/psn-pdf
October 13, 2021 - Safety culture as a patient safety practice for alarm
fatigue.
October 13, 2021
Winters BD, Slota JM, Bilimoria KY. Safety culture as a patient safety practice for alarm fatigue. JAMA.
2021;326(12):1207-1208. doi:10.1001/jama.2021.8316.
https://psnet.ahrq.gov/issue/safety-culture-patient-safety-practice-alarm-fati…
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psnet.ahrq.gov/node/836864/psn-pdf
April 06, 2022 - Improving the specificity of drug-drug interaction alerts:
can it be done?
April 6, 2022
Reese T, Wright A, Liu S, et al. Improving the specificity of drug-drug interaction alerts: Can it be done? Am
J Health Syst Pharm. 2022;79(13):1086-1095. doi:10.1093/ajhp/zxac045.
https://psnet.ahrq.gov/issue/improving-specif…
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psnet.ahrq.gov/node/45910/psn-pdf
March 08, 2017 - Electronically Generated Medication Administration and
Electronic Medication Administration Records for the
Prevention of Medication Transcription Errors: Review of
Clinical Effectiveness and Safety.
March 8, 2017
Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2016.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/39615/psn-pdf
December 17, 2010 - Computerized decision support for medication dosing in
renal insufficiency: a randomized, controlled trial.
December 17, 2010
Terrell KM, Perkins AJ, Hui SL, et al. Computerized decision support for medication dosing in renal
insufficiency: a randomized, controlled trial. Ann Emerg Med. 2010;56(6):623-9.
doi:10.10…
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psnet.ahrq.gov/node/40490/psn-pdf
June 01, 2011 - Standardized multidisciplinary protocol improves
handover of cardiac surgery patients to the intensive care
unit.
June 1, 2011
Joy BF, Elliott E, Hardy C, et al. Standardized multidisciplinary protocol improves handover of cardiac
surgery patients to the intensive care unit*. Pediatric Critical Care Medicine. 2010…