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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…
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psnet.ahrq.gov/node/837630/psn-pdf
July 06, 2022 - Mandating limits on workload, duty, and speed in
radiology.
July 6, 2022
Alexander R, Waite S, Bruno MA, et al. Mandating limits on workload, duty, and speed in radiology.
Radiology. 2022:212631. doi:10.1148/radiol.212631.
https://psnet.ahrq.gov/issue/mandating-limits-workload-duty-and-speed-radiology
To reduce m…
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psnet.ahrq.gov/node/45188/psn-pdf
June 01, 2016 - Reporting and second-order problem solving can turn
short-term fixes into long-term remedies.
June 1, 2016
ISMP Medication Safety Alert! Acute Care Edition. May 19, 2016;21:1-4.
https://psnet.ahrq.gov/issue/reporting-and-second-order-problem-solving-can-turn-short-term-fixes-long-
term-remedies
Workarounds are pr…
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psnet.ahrq.gov/node/839326/psn-pdf
November 02, 2022 - Safety considerations for challenges when using smart
infusion pumps.
November 2, 2022
ISMP Medication Safety Alert! Acute care edition. October 20, 2022;20(21):1-5.
https://psnet.ahrq.gov/issue/safety-considerations-challenges-when-using-smart-infusion-pumps
Errors due to inadequate information use with intraveno…
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psnet.ahrq.gov/node/837154/psn-pdf
May 18, 2022 - Survey shows room for improvement with three new best
practices for hospitals.
May 18, 2022
ISMP Medication Safety Alert! Acute care edition. May 5, 2022;27(9):1-5.
https://psnet.ahrq.gov/issue/survey-shows-room-improvement-three-new-best-practices-hospitals
Practice changes take time to be fully incorporate…
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psnet.ahrq.gov/node/43078/psn-pdf
June 03, 2014 - The value of autopsies in the era of high-tech medicine:
discrepant findings persist.
June 3, 2014
Kuijpers CCHJ, Fronczek J, van de Goot FRW, et al. The value of autopsies in the era of high-tech
medicine: discrepant findings persist. J Clin Pathol. 2014;67(6):512-9. doi:10.1136/jclinpath-2013-202122.
https://psn…
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psnet.ahrq.gov/node/40404/psn-pdf
February 10, 2015 - The quality 'journey' at Ascension Health: how we've
prevented at least 1,500 avoidable deaths a year—and aim
to do even better.
February 10, 2015
Pryor D, Hendrich A, Henkel RJ, et al. The quality 'journey' at Ascension Health: how we've prevented at
least 1,500 avoidable deaths a year--and aim to do even better.…
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psnet.ahrq.gov/node/38774/psn-pdf
July 08, 2009 - Evaluation of causes and frequency of medication errors
during information technology downtime.
July 8, 2009
Hanuscak TL, Szeinbach SL, Seoane-Vazquez E, et al. Evaluation of causes and frequency of medication
errors during information technology downtime. Am J Health Syst Pharm. 2009;66(12):1119-24.
doi:10.2146/a…
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psnet.ahrq.gov/node/60615/psn-pdf
June 24, 2020 - Key potentially inappropriate drugs in pediatrics: the KIDs
list.
June 24, 2020
Meyers RS, Thackray J, Matson KL, et al. Key potentially inappropriate drugs in pediatrics: the KIDs list. J
Pediatr Pharmacol Ther. 2020;25(3). doi:10.5863/1551-6776-25.3.175.
https://psnet.ahrq.gov/issue/key-potentially-inappropriate…
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psnet.ahrq.gov/node/850356/psn-pdf
June 14, 2023 - Prescribing errors in children: why they happen and how
to prevent them.
June 14, 2023
Conn R, Fox A, Carrington A, et al. Prescribing errors in children: why they happen and how to prevent
them. Pharmaceutical Journal. 2023;310:7973. doi:10.1211/pj.2023.1.184013.
https://psnet.ahrq.gov/issue/prescribing-errors-ch…
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psnet.ahrq.gov/node/45530/psn-pdf
October 19, 2016 - As a critical behavior to improve quality and patient
safety in health care: speaking up!
October 19, 2016
Nacioglu A. As a critical behavior to improve quality and patient safety in health care: speaking up!. Safety
in Health. 2016;2(1). doi:10.1186/s40886-016-0021-x.
https://psnet.ahrq.gov/issue/critical-behavio…
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psnet.ahrq.gov/node/43640/psn-pdf
November 12, 2014 - Infection prevention in the emergency department.
November 12, 2014
Liang SY, Theodoro DL, Schuur JD, et al. Infection prevention in the emergency department. Ann Emerg
Med. 2014;64(3):299-313. doi:10.1016/j.annemergmed.2014.02.024.
https://psnet.ahrq.gov/issue/infection-prevention-emergency-department
Emergency c…
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psnet.ahrq.gov/node/73185/psn-pdf
April 28, 2021 - Balancing patient safety, clinical efficacy, and
cybersecurity with clinician partners.
April 28, 2021
Schneider J, Wirth A. Balancing patient safety, clinical efficacy, and cybersecurity with clinician partners.
Biomed Instrum Technol. 2021;55(1):21-28. doi:10.2345/0899-8205-55.1.21.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/72852/psn-pdf
March 17, 2021 - Declaring uncertainty: using quality improvement
methods to change the conversation of diagnosis.
March 17, 2021
Ipsaro AJ, Patel SJ, Warner DC, et al. Declaring Uncertainty: Using Quality Improvement Methods to
Change the Conversation of Diagnosis. Hosp Pediatr. 2021;11(4):334-341. doi:10.1542/hpeds.2020-
000174.…
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psnet.ahrq.gov/node/854382/psn-pdf
October 11, 2023 - Battling alarm fatigue in the pediatric intensive care unit.
October 11, 2023
Herrera H, Wood D. Battling alarm fatigue in the pediatric intensive care unit. Crit Care Nurs Clin North Am.
2023;35(3):347-355. doi:10.1016/j.cnc.2023.05.003.
https://psnet.ahrq.gov/issue/battling-alarm-fatigue-pediatric-intensive-care-…
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psnet.ahrq.gov/node/44009/psn-pdf
July 18, 2016 - Automated communication tools and computer-based
medication reconciliation to decrease hospital discharge
medication errors.
July 18, 2016
Smith KJ, Handler S, Kapoor WN, et al. Automated Communication Tools and Computer-Based Medication
Reconciliation to Decrease Hospital Discharge Medication Errors. Am J Med Qua…
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psnet.ahrq.gov/node/42397/psn-pdf
September 05, 2013 - Impact of the World Health Organization's Surgical Safety
Checklist on safety culture in the operating theatre: a
controlled intervention study.
September 5, 2013
Haugen AS, Søfteland E, Eide GE, et al. Impact of the World Health Organization's Surgical Safety
Checklist on safety culture in the operating theatre: …
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Acute Respiratory Arrest in Pregnancy
Citation Text:
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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