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psnet.ahrq.gov/node/50940/psn-pdf
February 26, 2020 - The effect of smartphone-based application learning on
the nursing students' performance in preventing
medication errors in the pediatric units.
February 26, 2020
Pourteimour S, Hemmati MalsakPak M, Jasemi M, et al. The effect of smartphone-based application
learning on the nursing students' performance in prevent…
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psnet.ahrq.gov/node/44014/psn-pdf
March 20, 2019 - Patient Centered Medical Home Resource Center: Quality
and Safety.
March 20, 2019
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/patient-centered-medical-home-resource-center-quality-and-safety
The Patient Centered Medical Home (PCMH) concept reorganizes primary care services to ensure th…
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psnet.ahrq.gov/node/39332/psn-pdf
July 24, 2010 - Risk-sensitive events during laparoscopic
cholecystectomy: the influence of the integrated
operating room and a preoperative checklist tool.
July 24, 2010
Buzink SN, van Lier L, de Hingh IHJT, et al. Risk-sensitive events during laparoscopic cholecystectomy:
the influence of the integrated operating room and a pre…
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psnet.ahrq.gov/node/43888/psn-pdf
August 02, 2015 - Diagnostic performance by medical students working
individually or in teams.
August 2, 2015
Hautz WE, Kämmer JE, Schauber SK, et al. Diagnostic performance by medical students working
individually or in teams. JAMA. 2015;313(3):303-4. doi:10.1001/jama.2014.15770.
https://psnet.ahrq.gov/issue/diagnostic-performance…
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psnet.ahrq.gov/node/46519/psn-pdf
December 22, 2018 - Delirium in hospitalized older adults.
December 22, 2018
Marcantonio ER. Delirium in Hospitalized Older Adults. N Engl J Med. 2017;377(15):1456-1466.
doi:10.1056/NEJMcp1605501.
https://psnet.ahrq.gov/issue/delirium-hospitalized-older-adults
Delirium is considered a patient safety problem that can be prevented with…
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psnet.ahrq.gov/node/47464/psn-pdf
October 17, 2018 - How to prevent the top 4 medication errors.
October 17, 2018
Sederstrom J. Drug Topics. September 17, 2018.
https://psnet.ahrq.gov/issue/how-prevent-top-4-medication-errors
Medication errors continue to be a worldwide patient safety challenge that requires both systems and
individual practice strategies for improv…
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psnet.ahrq.gov/node/44410/psn-pdf
August 12, 2015 - Workarounds in the workplace: a second look.
August 12, 2015
Seaman JB, Erlen JA. Workarounds in the Workplace: A Second Look. Orthop Nurs. 2015;34(4):235-242.
doi:10.1097/NOR.0000000000000161.
https://psnet.ahrq.gov/issue/workarounds-workplace-second-look
Workarounds are prevalent in health care and create opport…
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psnet.ahrq.gov/node/44299/psn-pdf
November 06, 2015 - Nurse practitioner–led medication reconciliation in critical
access hospitals.
November 6, 2015
Young L, Barnason S, Hays K, et al. Nurse Practitioner–led Medication Reconciliation in Critical Access
Hospitals. The Journal for Nurse Practitioners. 2015;11(5). doi:10.1016/j.nurpra.2015.03.005.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/41911/psn-pdf
December 12, 2012 - Effects of an intervention to increase bed alarm use to
prevent falls in hospitalized patients: a cluster
randomized trial.
December 12, 2012
Shorr RI, Chandler M, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in
hospitalized patients: a cluster randomized trial. Ann Intern …
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psnet.ahrq.gov/node/50575/psn-pdf
October 23, 2019 - Dynamic pocket card for implementing ISBAR in shift
handover communication.
October 23, 2019
Schmidt T, Kocher DR, Mahendran P, et al. Dynamic Pocket Card for Implementing ISBAR in Shift
Handover Communication. Stud Health Technol Inform. 2019;267:224-229. doi:10.3233/SHTI190831.
https://psnet.ahrq.gov/issue/dynam…
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psnet.ahrq.gov/node/46322/psn-pdf
August 02, 2017 - Sophisticated digital aids could help determine what ails
you.
August 2, 2017
Maron DF. Scientific American. July 21, 2017.
https://psnet.ahrq.gov/issue/sophisticated-digital-aids-could-help-determine-what-ails-you
Clinical decision support systems are a key strategy to improve diagnostic accuracy. This magazine a…
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psnet.ahrq.gov/node/41633/psn-pdf
January 01, 2013 - Determinants of success of quality improvement
collaboratives: what does the literature show?
December 31, 2012
Hulscher M, Schouten LMT, Grol R, et al. Determinants of success of quality improvement collaboratives:
what does the literature show? BMJ Qual Saf. 2013;22(1):19-31. doi:10.1136/bmjqs-2011-000651.
https…
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psnet.ahrq.gov/node/45682/psn-pdf
November 01, 2017 - Changing smart pump vendors: lessons learned.
November 1, 2017
Arthur KJ, Catlin AC, Quebe A, et al. Changing Smart Pump Vendors: Lessons Learned. Hosp Pharm.
2016;51(9):782-789.
https://psnet.ahrq.gov/issue/changing-smart-pump-vendors-lessons-learned
Changes in processes, devices, and technologies can increase ri…
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psnet.ahrq.gov/node/72591/psn-pdf
December 23, 2020 - Bias and racism teaching rounds at an academic medical
center.
December 23, 2020
Capers Q, Bond DA, Nori US. Bias and racism teaching rounds at an academic medical center. Chest.
2020;158(6):2688-2694. doi:10.1016/j.chest.2020.08.2073.
https://psnet.ahrq.gov/issue/bias-and-racism-teaching-rounds-academic-medical-c…
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psnet.ahrq.gov/node/43733/psn-pdf
March 14, 2016 - The effect of an electronic checklist on critical care
provider workload, errors, and performance.
March 14, 2016
Thongprayoon C, Harrison AM, O'Horo JC, et al. The Effect of an Electronic Checklist on Critical Care
Provider Workload, Errors, and Performance. J Intensive Care Med. 2016;31(3):205-12.
doi:10.1177/08…
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psnet.ahrq.gov/node/35971/psn-pdf
May 27, 2011 - Effectiveness of computerized provider order entry with
dose range checking on prescribing errors.
May 27, 2011
Boling B, McKibben M, Hingl J, et al. Effectiveness of Computerized Provider Order Entry with Dose Range
Checking on Prescribing Errors. J Patient Saf. 2008;1(4). doi:10.1097/01.jps.0000215339.03807.fd.
…
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psnet.ahrq.gov/node/45987/psn-pdf
April 26, 2017 - Using simulation to prepare nursing staff for the move to
a new building.
April 26, 2017
Knippa S, Senecal P-A. Using Simulation to Prepare Nursing Staff for the Move to a New Building. J
Nurses Prof Dev. 2017;33(2):E1-E5. doi:10.1097/NND.0000000000000329.
https://psnet.ahrq.gov/issue/using-simulation-prepare-nurs…
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psnet.ahrq.gov/node/45611/psn-pdf
May 27, 2025 - Funding Announcement for Projects Targeting the
Reduction of Healthcare-Associated Infections.
July 7, 2021
Rockville, MD: Agency for Healthcare Research and Quality; July 7 2021.
https://psnet.ahrq.gov/issue/funding-announcement-projects-targeting-reduction-healthcare-associated-
infections
Health care–associate…
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psnet.ahrq.gov/node/44843/psn-pdf
September 06, 2016 - Addressing the Global Shortages of Medicines, and the
Safety and Accessibility of Children's Medication.
September 6, 2016
Geneva, Switzerland: World Health Organization; 2015.
https://psnet.ahrq.gov/issue/addressing-global-shortages-medicines-and-safety-and-accessibility-childrens-
medication
Drug shortages have…
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psnet.ahrq.gov/node/72687/psn-pdf
January 27, 2021 - Learning from errors with the new COVID-19 vaccines.
January 27, 2021
ISMP Medication Safety Alert! Acute Care Edition. January 14, 2021;26(1);1-5.
https://psnet.ahrq.gov/issue/learning-errors-new-covid-19-vaccines
Learning from error rests on transparency efforts buttressed by frontline reports. This a…