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psnet.ahrq.gov/node/61047/psn-pdf
October 21, 2020 - COVID-19: an emerging threat to antibiotic stewardship in
the emergency department.
October 21, 2020
Pulia M, Wolf I, Schulz L, et al. COVID-19: an emerging threat to antibiotic stewardship in the emergency
department. West J Emerg Med. 2020;21(5):1283-1286. doi:10.5811/westjem.2020.7.48848.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/45373/psn-pdf
November 18, 2016 - Prevalence, risk factors, and outcomes of idle
intravenous catheters: an integrative review.
November 18, 2016
Becerra MB, Shirley D, Safdar N. Prevalence, risk factors, and outcomes of idle intravenous catheters: An
integrative review. Am J Infect Control. 2016;44(10):e167-e172. doi:10.1016/j.ajic.2016.03.073.
ht…
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psnet.ahrq.gov/node/866250/psn-pdf
July 10, 2024 - Attention among health care professionals : a scoping
review.
July 10, 2024
Kissler MJ, Porter S, Knees M, et al. Attention among health care professionals : a scoping review. Ann
Intern Med. 2024;177(7):941-952. doi:10.7326/m23-3229.
https://psnet.ahrq.gov/issue/attention-among-health-care-professionals-scoping-r…
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psnet.ahrq.gov/node/861285/psn-pdf
January 24, 2024 - Analysis of a medication safety intervention in the
pediatric emergency department.
January 24, 2024
Samuels-Kalow ME, Tassone R, Manning W, et al. Analysis of a medication safety intervention in the
pediatric emergency department. JAMA Netw Open. 2024;7(1):e2351629.
doi:10.1001/jamanetworkopen.2023.51629.
https:…
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psnet.ahrq.gov/node/45440/psn-pdf
November 09, 2016 - Safety lessons from the NIH Clinical Center.
November 9, 2016
Gandhi TK. Safety Lessons from the NIH Clinical Center. N Engl J Med. 2016;375(18):1705-1707.
https://psnet.ahrq.gov/issue/safety-lessons-nih-clinical-center
System failures can remain undetected over time in large organizations. This perspective describ…
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psnet.ahrq.gov/node/73298/psn-pdf
May 19, 2021 - The Future of Nursing 2020-2030: Charting a Path to
Achieve Health Equity.
May 19, 2021
National Academies of Sciences, Engineering, and Medicine. Washington DC: National
Academies Press; 2021. ISBN: 9780309685061.
https://psnet.ahrq.gov/issue/future-nursing-2020-2030-charting-path-achieve-he…
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psnet.ahrq.gov/node/74129/psn-pdf
January 01, 2022 - Factors influencing providers' willingness to deprescribe
medications.
December 1, 2021
Davila H, Rosen AK, Stolzmann K, et al. Factors influencing providers' willingness to deprescribe
medications. J Am Coll Clin Pharm. 2022;5:15-25. doi:10.1002/jac5.1537.
https://psnet.ahrq.gov/issue/factors-influencing-provider…
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psnet.ahrq.gov/node/34730/psn-pdf
October 29, 2013 - Medication Errors. 2nd ed.
October 29, 2013
Cohen MR, ed. Washington DC: American Pharmacists Association; 2007.
https://psnet.ahrq.gov/issue/medication-errors-2nd-ed
Cohen, executive director of the Institute for Safe Medication Practices (ISMP), combined 25 years of
experience as a leader in medication safety wi…
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psnet.ahrq.gov/node/35048/psn-pdf
June 22, 2009 - Reduction in warfarin adverse events requiring patient
hospitalization after implementation of a pharmacist-
managed anticoagulation service.
June 22, 2009
Locke C, Ravnan SL, Patel R, et al. Reduction in warfarin adverse events requiring patient hospitalization
after implementation of a pharmacist-managed anticoa…
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psnet.ahrq.gov/node/41541/psn-pdf
September 26, 2012 - Failures in communication and information transfer
across the surgical care pathway: interview study.
September 26, 2012
Nagpal K, Arora S, Vats A, et al. Failures in communication and information transfer across the surgical
care pathway: interview study. BMJ Qual Saf. 2012;21(10):843-9.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/46776/psn-pdf
February 28, 2018 - Older adults' awareness of deprescribing: a population-
based survey.
February 28, 2018
Turner JP, Tannenbaum C. Older adults' awareness of deprescribing: a population-based survey. J Am
Geriatr Soc. 2017;65(12):2691-2696. doi:10.1111/jgs.15079.
https://psnet.ahrq.gov/issue/older-adults-awareness-deprescribing-pop…
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psnet.ahrq.gov/node/866406/psn-pdf
July 31, 2024 - Impact of a daily huddle on safety in perioperative
services.
July 31, 2024
Tuyishime H, Claure RE, Balakrishnan K, et al. Impact of a daily huddle on safety in perioperative services.
Jt Comm J Qual Patient Saf. 2024;50(9):678-683. doi:10.1016/j.jcjq.2024.04.012.
https://psnet.ahrq.gov/issue/impact-daily-huddle-s…
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psnet.ahrq.gov/node/45469/psn-pdf
January 18, 2017 - Tamper-resistant drugs cannot solve the opioid crisis.
January 18, 2017
Leece P, Orkin AM, Kahan M. Tamper-resistant drugs cannot solve the opioid crisis. CMAJ.
2015;187(10):717-718. doi:10.1503/cmaj.150329.
https://psnet.ahrq.gov/issue/tamper-resistant-drugs-cannot-solve-opioid-crisis
Health care organizations ha…
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psnet.ahrq.gov/node/44787/psn-pdf
January 20, 2016 - Medication errors involving overrides of healthcare
technology.
January 20, 2016
Grissinger M. PA-PSRS Patient Saf Advis. December 2015;12:141-148.
https://psnet.ahrq.gov/issue/medication-errors-involving-overrides-healthcare-technology
Users often bypass alerts meant to enhance safety of medication ordering and d…
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psnet.ahrq.gov/node/50925/psn-pdf
February 19, 2020 - Report of the Independent Inquiry into the Issues Raised
by Paterson.
February 19, 2020
James G. House Commons Report 31. Department of Health and Social Care. London,
England: Crown Copyright; 2020. ISBN 9781528617284.
https://psnet.ahrq.gov/issue/report-independent-inquiry-issues-raised-paterson
Shari…
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psnet.ahrq.gov/node/46554/psn-pdf
October 25, 2017 - Severe hyperglycemia in patients incorrectly using insulin
pens at home.
October 25, 2017
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American
Society of Health-System Pharmacists. October 12, 2017.
https://psnet.ahrq.gov/issue/severe-hyperglycemia-patients-incorrect…
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psnet.ahrq.gov/node/847733/psn-pdf
March 16, 2025 - ISMP Targeted Medication Safety Best Practices for
Community Pharmacy.
March 16, 2025
Institute for Safe Medication Practices: March 2025.
https://psnet.ahrq.gov/issue/ismp-targeted-medication-safety-best-practices-community-pharmacy
Community pharmacies are common providers of medication delivery that harbor proc…
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psnet.ahrq.gov/node/42117/psn-pdf
March 20, 2013 - Nurse–patient ratios as a patient safety strategy: a
systematic review.
March 20, 2013
Shekelle PG. Nurse-patient ratios as a patient safety strategy: a systematic review. Ann Intern Med.
2013;158(5 Pt 2):404-409. doi:10.7326/0003-4819-158-5-201303051-00007.
https://psnet.ahrq.gov/issue/nurse-patient-ratios-patien…
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psnet.ahrq.gov/node/46931/psn-pdf
January 15, 2019 - Strategies for optimizing OR drug safety.
January 15, 2019
Meyer TA, McAllister RK. Pharmacy Practice News. March 19, 2018.
https://psnet.ahrq.gov/issue/strategies-optimizing-or-drug-safety
Perioperative adverse drug events are common and understudied. Reporting on the complexity of
medication administration durin…
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psnet.ahrq.gov/node/45764/psn-pdf
April 11, 2018 - Pediatric anesthesiology fellows' perception of quality of
attending supervision and medical errors.
April 11, 2018
Benzon HA, Hajduk J, De Oliveira GS, et al. Pediatric Anesthesiology Fellows' Perception of Quality of
Attending Supervision and Medical Errors. Anesth Analg. 2018;126(2):639-643.
doi:10.1213/ANE.000…