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psnet.ahrq.gov/node/43080/psn-pdf
March 26, 2014 - Hospital-based transfusion error tracking from 2005 to
2010: identifying the key errors threatening patient
transfusion safety.
March 26, 2014
Maskens C, Downie H, Wendt A, et al. Hospital-based transfusion error tracking from 2005 to 2010:
identifying the key errors threatening patient transfusion safety. Transfu…
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psnet.ahrq.gov/node/60954/psn-pdf
September 30, 2020 - Catheter-associated urinary tract infection reduction in a
pediatric safety engagement network.
September 30, 2020
Foster CB, Ackerman K, Hupertz V, et al. Catheter-associated urinary tract infection reduction in a pediatric
safety engagement network. Pediatrics. 2020;146(4):e20192057. doi:10.1542/peds.2019-2057.
…
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psnet.ahrq.gov/node/35130/psn-pdf
March 11, 2011 - A trial of automated decision support alerts for
contraindicated medications using computerized
physician order entry.
March 11, 2011
Galanter W, Didomenico RJ, Polikaitis A. A trial of automated decision support alerts for contraindicated
medications using computerized physician order entry. J Am Med Inform Assoc…
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psnet.ahrq.gov/node/836986/psn-pdf
April 27, 2022 - Habit and automaticity in medical alert override: cohort
study.
April 27, 2022
Wang L, Goh KH, Yeow A, et al. Habit and automaticity in medical alert override: cohort study. J Med
Internet Res. 2022;24(2):e23355. doi:10.2196/23355.
https://psnet.ahrq.gov/issue/habit-and-automaticity-medical-alert-override-cohort-s…
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psnet.ahrq.gov/node/865978/psn-pdf
May 29, 2024 - Ensuring safe and equitable discharge: a quality
improvement initiative for individuals with hypertensive
disorders of pregnancy.
May 29, 2024
Zacherl KM, Sterrett EC, Hughes BL, et al. Ensuring safe and equitable discharge: a quality improvement
initiative for individuals with hypertensive disorders of pregnancy.…
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psnet.ahrq.gov/node/43836/psn-pdf
March 11, 2015 - Hospital organisation, management, and structure for
prevention of health-care-associated infection: a
systematic review and expert consensus.
March 11, 2015
Zingg W, Holmes A, Dettenkofer M, et al. Hospital organisation, management, and structure for prevention
of health-care-associated infection: a systematic re…
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psnet.ahrq.gov/node/36244/psn-pdf
June 13, 2012 - With Safety in Mind: Mental Health Services and Patient
Safety.
June 13, 2012
Scobie S, Minghella E, Dale C, et al. London, UK: National Patient Safety Agency; 2006.
https://psnet.ahrq.gov/issue/safety-mind-mental-health-services-and-patient-safety
This report, the second in a series from the United Kingdom's Nati…
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psnet.ahrq.gov/node/74710/psn-pdf
January 26, 2022 - The evolution of the Anesthesia Patient Safety Movement
in America: lessons learned and considerations to
promote further improvement in patient safety.
January 26, 2022
Warner MA, Warner ME. The evolution of the Anesthesia Patient Safety Movement in America: lessons
learned and considerations to promote further i…
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psnet.ahrq.gov/node/42489/psn-pdf
May 19, 2014 - Improving medication administration safety in solid organ
transplant patients through barcode-assisted medication
administration.
May 19, 2014
Bonkowski J, Weber RJ, Melucci J, et al. Improving medication administration safety in solid organ
transplant patients through barcode-assisted medication administration. A…
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psnet.ahrq.gov/node/44072/psn-pdf
August 02, 2015 - The rise of the medical scribe industry: implications for
the advancement of electronic health records.
August 2, 2015
Gellert GA, Ramirez R, Webster L. The rise of the medical scribe industry: implications for the
advancement of electronic health records. JAMA. 2015;313(13):1315-1316. doi:10.1001/jama.2014.17128.
…
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psnet.ahrq.gov/node/43830/psn-pdf
February 04, 2015 - A combined teamwork training and work standardisation
intervention in operating theatres: controlled interrupted
time series study.
February 4, 2015
Morgan L, Pickering S, Hadi M, et al. A combined teamwork training and work standardisation intervention
in operating theatres: controlled interrupted time series stu…
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psnet.ahrq.gov/node/40471/psn-pdf
May 25, 2011 - Effect of admission medication reconciliation on adverse
drug events from admission medication changes.
May 25, 2011
Boockvar K, Blum S, Kugler A, et al. Effect of admission medication reconciliation on adverse drug events
from admission medication changes. Arch Intern Med. 2011;171(9):860-1.
doi:10.1001/archinter…
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psnet.ahrq.gov/node/46597/psn-pdf
November 01, 2017 - A novel process audit for standardized perioperative
handoff protocols.
November 1, 2017
Pallekonda V, Scholl AT, McKelvey GM, et al. A Novel Process Audit for Standardized Perioperative
Handoff Protocols. Jt Comm J Qual Patient Saf. 2017;43(11):611-618. doi:10.1016/j.jcjq.2017.04.011.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/73612/psn-pdf
August 18, 2021 - Evaluating the impact of radio frequency identification
retained surgical instruments tracking on patient safety:
literature review.
August 18, 2021
Schnock KO, Biggs B, Fladger A, et al. Evaluating the impact of radio frequency identification retained
surgical instruments tracking on patient safety: literature re…
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psnet.ahrq.gov/node/43109/psn-pdf
December 10, 2014 - Creating a physician-led quality imperative.
December 10, 2014
Nelson MF, Merriman CS, Magnusson PT, et al. Creating a physician-led quality imperative. Am J Med
Qual. 2014;29(6):508-16. doi:10.1177/1062860613509683.
https://psnet.ahrq.gov/issue/creating-physician-led-quality-imperative
This commentary relates one…
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psnet.ahrq.gov/node/45228/psn-pdf
June 29, 2016 - An innovative approach to the surgical time out: a patient-
focused model.
June 29, 2016
Kozusko SD, Elkwood L, Gaynor D, et al. An Innovative Approach to the Surgical Time Out: A Patient-
Focused Model. AORN J. 2016;103(6):617-22. doi:10.1016/j.aorn.2016.04.001.
https://psnet.ahrq.gov/issue/innovative-approach-su…
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psnet.ahrq.gov/node/844748/psn-pdf
February 15, 2023 - 'They were his best shot. And they failed to help’: why did
EMS workers neglect Tyre Nichols?
February 15, 2023
Renault M. STAT. February 6, 2023.
https://psnet.ahrq.gov/issue/they-were-his-best-shot-and-they-failed-help-why-did-ems-workers-neglect-
tyre-nichols
Emergent care situations are vulnerable to a range …
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psnet.ahrq.gov/node/46633/psn-pdf
November 22, 2017 - The high costs of unnecessary care.
November 22, 2017
Carroll AE. The High Costs of Unnecessary Care. JAMA. 2017;318(18):1748-1749.
doi:10.1001/jama.2017.16193.
https://psnet.ahrq.gov/issue/high-costs-unnecessary-care
The provision of unneeded care can result in physical, financial, and psychological harm to patie…
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psnet.ahrq.gov/node/46130/psn-pdf
June 21, 2017 - High 5s initiative: implementation of medication
reconciliation in France a 5 years experimentation.
June 21, 2017
Dufay É, Doerper S, Michel B, et al. High 5s initiative: implementation of medication reconciliation in France
a 5 years experimentation. Safety in Health. 2017;3(1):6. doi:10.1186/s40886-017-0057-6.
…
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psnet.ahrq.gov/node/46311/psn-pdf
August 23, 2017 - Swimming against the tide: primary care physicians'
views on deprescribing in everyday practice.
August 23, 2017
Wallis KA, Andrews A, Henderson M. Swimming Against the Tide: Primary Care Physicians’ Views on
Deprescribing in Everyday Practice. Ann Fam Med. 2017;15(4):341-346. doi:10.1370/afm.2094.
https://psnet.a…