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psnet.ahrq.gov/node/73522/psn-pdf
July 21, 2021 - Federal speech rulings may embolden health care
workers to call out safety issues.
July 21, 2021
Meyer H. Kaiser Health News. July 9, 2021.
https://psnet.ahrq.gov/issue/federal-speech-rulings-may-embolden-health-care-workers-call-out-safety-
issues
Whistleblower protections are a key component to raising awarenes…
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psnet.ahrq.gov/node/44791/psn-pdf
January 13, 2016 - FDA Drug Safety Communication: FDA cautions about
dosing errors when switching between different oral
formulations of antifungal Noxafil (posaconazole); label
changes approved.
January 13, 2016
US Food and Drug Administration; FDA.
https://psnet.ahrq.gov/issue/fda-drug-safety-communication-fda-cautions-about-dosi…
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psnet.ahrq.gov/node/46813/psn-pdf
March 14, 2018 - Our other prescription drug problem.
March 14, 2018
Lembke A, Papac J, Humphreys K. Our Other Prescription Drug Problem. N Engl J Med. 2018;378(8):693-
695. doi:10.1056/NEJMp1715050.
https://psnet.ahrq.gov/issue/our-other-prescription-drug-problem
Unintended consequences can emerge when targeted strategies divert …
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psnet.ahrq.gov/node/34724/psn-pdf
May 27, 2011 - From patients to politicians: a cognitive engineering view
of patient safety.
May 27, 2011
Vicente KJ. From patients to politicians: a cognitive engineering view of patient safety. Qual Saf Health
Care. 2002;11(4):302-4.
https://psnet.ahrq.gov/issue/patients-politicians-cognitive-engineering-view-patient-safety
V…
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psnet.ahrq.gov/node/48036/psn-pdf
July 10, 2019 - Can positivity promote safety? Psychological capital
development combats cynicism and unsafe behavior.
July 10, 2019
Stratman JL, Youssef-Morgan CM. Can positivity promote safety? Psychological capital development
combats cynicism and unsafe behavior. Safety Sci. 2019;116:13-25. doi:10.1016/j.ssci.2019.02.031.
htt…
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psnet.ahrq.gov/node/846465/psn-pdf
March 22, 2023 - Difficult diagnosis in the ICU: making the right call but
beware uncertainty and bias.
March 22, 2023
Pisciotta W, Arina P, Hofmaenner D, et al. Difficult diagnosis in the ICU: making the right call but beware
uncertainty and bias. Anaesthesia. 2023;78(4):501-509. doi:10.1111/anae.15897.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/45422/psn-pdf
October 12, 2016 - Maths anxiety and medication dosage calculation errors:
a scoping review.
October 12, 2016
Williams B, Davis S. Maths anxiety and medication dosage calculation errors: A scoping review. Nurse
Educ Pract. 2016;20:139-46. doi:10.1016/j.nepr.2016.08.005.
https://psnet.ahrq.gov/issue/maths-anxiety-and-medication-dosag…
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psnet.ahrq.gov/node/45403/psn-pdf
September 21, 2016 - 'Superbug' scourge spreads as U.S. fails to track rising
human toll.
September 21, 2016
McNeill R, Nelson DJ, Abutaleb Y. Reuters Investigation. September 7, 2016.
https://psnet.ahrq.gov/issue/superbug-scourge-spreads-us-fails-track-rising-human-toll
Antimicrobial resistance is a pervasive threat to patient safety…
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psnet.ahrq.gov/node/37547/psn-pdf
February 20, 2008 - Intensive care unit nurses' perceptions of safety after a
highly specific safety intervention.
February 20, 2008
Elder NC, Brungs SM, Nagy M, et al. Intensive care unit nurses' perceptions of safety after a highly specific
safety intervention. Qual Saf Health Care. 2008;17(1):25-30. doi:10.1136/qshc.2006.021949.
h…
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psnet.ahrq.gov/node/47271/psn-pdf
August 08, 2018 - NAM Action Collaborative on Countering the U.S. Opioid
Epidemic.
August 8, 2018
National Academy of Medicine; Aspen Institute.
https://psnet.ahrq.gov/issue/nam-action-collaborative-countering-us-opioid-epidemic
Despite increased awareness regarding the public health impacts of opioid misuse and overdose in the
Un…
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psnet.ahrq.gov/node/35635/psn-pdf
June 24, 2010 - Patient safety problems in adolescent medical care.
June 24, 2010
Woods D, Holl JL, Klein JD, et al. Patient safety problems in adolescent medical care. J Adolesc Health.
2006;38(1):5-12.
https://psnet.ahrq.gov/issue/patient-safety-problems-adolescent-medical-care
Using data from the Colorado and Utah Medical Prac…
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psnet.ahrq.gov/node/61033/psn-pdf
October 14, 2020 - L.A.’s poorest patients endure long delays to see medical
specialists. Some die waiting.
October 14, 2020
Dolan J, Mejia B. Los Angeles Times. September 30, 2020.
https://psnet.ahrq.gov/issue/las-poorest-patients-endure-long-delays-see-medical-specialists-some-die-
waiting
Socioeconomic conditions influence acces…
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psnet.ahrq.gov/node/45444/psn-pdf
December 04, 2016 - Alarm fatigue: use of an evidence-based alarm
management strategy.
December 4, 2016
Turmell JW, Coke L, Catinella R, et al. Alarm Fatigue. J Nurs Care Qual. 2016;32(1):47-54.
doi:10.1097/ncq.0000000000000223.
https://psnet.ahrq.gov/issue/alarm-fatigue-use-evidence-based-alarm-management-strategy
Reducing nuisance…
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psnet.ahrq.gov/node/34914/psn-pdf
February 27, 2009 - Drug error in anaesthetic practice: a review of 896 reports
from the Australian Incident Monitoring Study database.
February 27, 2009
Abeysekera A, Bergman IJ, Kluger MT, et al. Drug error in anaesthetic practice: a review of 896 reports
from the Australian Incident Monitoring Study database. Anaesthesia. 2005;60(3…
-
psnet.ahrq.gov/node/866809/psn-pdf
September 25, 2024 - Stop the line: interventions to prevent retained surgical
items.
September 25, 2024
Angelilli S. Stop the line: interventions to prevent retained surgical items. AORN J. 2024;120(2):71-81.
doi:10.1002/aorn.14190.
https://psnet.ahrq.gov/issue/stop-line-interventions-prevent-retained-surgical-items
Retained surgica…
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psnet.ahrq.gov/node/50626/psn-pdf
November 06, 2019 - Prevalence of medication transfer errors in nephrology
patients and potential risk factors.
November 6, 2019
Ebbens MM, Errami H, Moes DJAR, et al. Prevalence of medication transfer errors in nephrology patients
and potential risk factors. Eur J Intern Med. 2019;70:50-53. doi:10.1016/j.ejim.2019.09.003.
https://ps…
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psnet.ahrq.gov/node/46808/psn-pdf
February 14, 2018 - Anesthesia medication handling needs a new vision.
February 14, 2018
Grigg EB, Roesler A. Anesthesia Medication Handling Needs a New Vision. Anesth Analg.
2018;126(1):346-350. doi:10.1213/ANE.0000000000002521.
https://psnet.ahrq.gov/issue/anesthesia-medication-handling-needs-new-vision
Anesthesiology has been a le…
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psnet.ahrq.gov/node/866966/psn-pdf
October 16, 2024 - Diagnostic Excellence in U.S. Rural Healthcare: A Call to
Action.
October 16, 2024
Ali KJ, Galvez NJ, Craig S, et al. Diagnostic Excellence In U.s. Rural Healthcare: A Call To Action.
Rockville, MD: Agency for Healthcare Research and Quality; September 2024. AHRQ Publication No. 24-
0010-9-EF
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/46671/psn-pdf
June 25, 2018 - Twelve tips for embedding human factors and
ergonomics principles in healthcare education.
June 25, 2018
Vosper H, Hignett S, Bowie P. Twelve tips for embedding human factors and ergonomics principles in
healthcare education. Med Teach. 2017;40(4):357-363. doi:10.1080/0142159x.2017.1387240.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/60007/psn-pdf
March 04, 2020 - ISMP Guidelines for Optimizing Safe Implementation and
Use of Smart Infusion Pumps.
March 4, 2020
Horsham, PA: Institute for Safe Medication Practices; 2020.
https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-implementation-and-use-smart-infusion-
pumps
Smart pumps are widely available as a medicat…