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psnet.ahrq.gov/node/40145/psn-pdf
November 14, 2011 - Postoperative sepsis in the United States.
November 14, 2011
Vogel TR, Dombrovskiy VY, Carson JL, et al. Postoperative sepsis in the United States. Ann Surg.
2010;252(6):1065-71. doi:10.1097/SLA.0b013e3181dcf36e.
https://psnet.ahrq.gov/issue/postoperative-sepsis-united-states
The safety of patients undergoing surg…
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psnet.ahrq.gov/node/46657/psn-pdf
December 16, 2017 - Diagnostic accuracy of pediatric teledermatology using
parent-submitted photographs: a randomized clinical trial.
December 16, 2017
O'Connor DM, Jew OS, Perman MJ, et al. Diagnostic Accuracy of Pediatric Teledermatology Using Parent-
Submitted Photographs: A Randomized Clinical Trial. JAMA Dermatol. 2017;153(12):12…
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psnet.ahrq.gov/node/42909/psn-pdf
December 12, 2014 - Does applying technology throughout the medication use
process improve patient safety with antineoplastics?
December 12, 2014
Bubalo J, Warden BA, Wiegel JJ, et al. Does applying technology throughout the medication use process
improve patient safety with antineoplastics? J Oncol Pharm Pract. 2014;20(6):445-60.
do…
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psnet.ahrq.gov/node/836829/psn-pdf
March 30, 2022 - Safety in fragile, conflict-affected, and vulnerable
settings: An evidence scanning approach for identifying
patient safety interventions.
March 30, 2022
O’Brien N, Shaw A, Flott K, et al. Safety in fragile, conflict-affected, and vulnerable settings: an evidence
scanning approach for identifying patient safety in…
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psnet.ahrq.gov/node/44162/psn-pdf
May 27, 2015 - Computerised clinical decision support systems to
improve medication safety in long-term care homes: a
systematic review.
May 27, 2015
Marasinghe KM. Computerised clinical decision support systems to improve medication safety in long-term
care homes: a systematic review. BMJ Open. 2015;5(5):e006539. doi:10.1136/bm…
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psnet.ahrq.gov/node/44207/psn-pdf
August 21, 2018 - U.S. compounding pharmacy-related outbreaks, 2001--
2013: public health and patient safety lessons learned.
August 21, 2018
Shehab N, Brown MN, Kallen AJ, et al. U.S. compounding pharmacy-related outbreaks, 2001--2013: public
health and patient safety lessons learned. J Patient Saf. 2018;14(3):164-173.
doi:10.1097…
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psnet.ahrq.gov/node/45192/psn-pdf
December 04, 2016 - Evidence summary and recommendations for improved
communication during care transitions.
December 4, 2016
Jackson PD, Biggins MS, Cowan L, et al. Evidence Summary and Recommendations for Improved
Communication during Care Transitions. Rehabil Nurs. 2016;41(3):135-48. doi:10.1002/rnj.230.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/46566/psn-pdf
June 25, 2018 - A systematic review of interventions to follow-up test
results pending at discharge.
June 25, 2018
Darragh PJ, Bodley T, Orchanian-Cheff A, et al. A Systematic Review of Interventions to Follow-Up Test
Results Pending at Discharge. J Gen Intern Med. 2018;33(5):750-758. doi:10.1007/s11606-017-4290-9.
https://psnet.…
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psnet.ahrq.gov/node/47121/psn-pdf
August 08, 2018 - Assessment of programs aimed to decrease or prevent
mistreatment of medical trainees.
August 8, 2018
Mazer LM, Bereknyei Merrell S, Hasty BN, et al. Assessment of Programs Aimed to Decrease or Prevent
Mistreatment of Medical Trainees. JAMA Netw Open. 2018;1(3):e180870.
doi:10.1001/jamanetworkopen.2018.0870.
https…
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psnet.ahrq.gov/node/43799/psn-pdf
January 07, 2015 - Omission of high-alert medications: a hidden danger.
January 7, 2015
Grissinger M, Alghamdi D. PA-PSRS Patient Saf Advis. December 2014;11:149-155.
https://psnet.ahrq.gov/issue/omission-high-alert-medications-hidden-danger
Analyzing incidents reported over a 4-month period, this article reveals that 21% of 2700 med…
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psnet.ahrq.gov/node/39602/psn-pdf
August 09, 2013 - Postoperative handover: problems, pitfalls, and
prevention of error.
August 9, 2013
Nagpal K, Arora S, Abboudi M, et al. Postoperative handover: problems, pitfalls, and prevention of error.
Ann Surg. 2010;252(1):171-6. doi:10.1097/SLA.0b013e3181dc3656.
https://psnet.ahrq.gov/issue/postoperative-handover-problems-p…
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psnet.ahrq.gov/node/60616/psn-pdf
June 24, 2020 - Nurse-reported bullying and documented adverse patient
events: an exploratory study in a US Hospital.
June 24, 2020
Arnetz JE, Neufcourt L, Sudan S, et al. Nurse-reported bullying and documented adverse patient events:
an exploratory study in a US Hospital. J Nurs Care Qual. 2020;35(3):206-212.
doi:10.1097/ncq.000…
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psnet.ahrq.gov/node/851645/psn-pdf
July 26, 2023 - Anticoagulation-associated adverse drug events in
hospitalized patients across two time periods.
July 26, 2023
Fanikos J, Tawfik Y, Almheiri D, et al. Anticoagulation-associated adverse drug events in hospitalized
patients across two time periods. Am J Med. 2023;136(9):927-936. doi:10.1016/j.amjmed.2023.05.013.
ht…
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psnet.ahrq.gov/node/45919/psn-pdf
July 05, 2017 - Managing the patient identification crisis in healthcare
and laboratory medicine.
July 5, 2017
Lippi G, Mattiuzzi C, Bovo C, et al. Managing the patient identification crisis in healthcare and laboratory
medicine. Clin Biochem. 2017;50(10-11):562-567. doi:10.1016/j.clinbiochem.2017.02.004.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/45851/psn-pdf
February 22, 2017 - Eight years of decreased methicillin-resistant
Staphylococcus aureus health care–associated infections
associated with a Veterans Affairs prevention initiative.
February 22, 2017
Evans ME, Kralovic SM, Simbartl LA, et al. Eight years of decreased methicillin-resistant Staphylococcus
aureus health care-associated i…
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psnet.ahrq.gov/node/47607/psn-pdf
February 13, 2019 - Infection prevention in long-term care: re-evaluating the
system using a human factors engineering approach.
February 13, 2019
Katz MJ, Gurses AP. Infection prevention in long-term care: re-evaluating the system using a human
factors engineering approach. Infect Control Hosp Epidemiol. 2019;40(1):95-99. doi:10.1017…
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psnet.ahrq.gov/node/867388/psn-pdf
December 18, 2024 - Secure messaging use and wrong-patient ordering errors
among inpatient clinicians.
December 18, 2024
Lou SS, Lew D, Xia L, et al. Secure messaging use and wrong-patient ordering errors among inpatient
clinicians. JAMA Netw Open. 2024;7(12):e2447797. doi:10.1001/jamanetworkopen.2024.47797.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/45699/psn-pdf
December 21, 2016 - Towards a new paradigm in laboratory medicine: the five
rights.
December 21, 2016
Plebani M. Towards a new paradigm in laboratory medicine: the five rights. Clin Chem Lab Med.
2016;54(12):1881-1891. doi:10.1515/cclm-2016-0848.
https://psnet.ahrq.gov/issue/towards-new-paradigm-laboratory-medicine-five-rights
Error…
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psnet.ahrq.gov/node/44456/psn-pdf
September 02, 2015 - Tackling communication barriers between long-term care
facility and emergency department transfers to improve
medication safety in older adults.
September 2, 2015
Callinan SM, Brandt NJ. Tackling communication barriers between long-term care facility and emergency
department transfers to improve medication safety …
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psnet.ahrq.gov/node/44238/psn-pdf
November 03, 2015 - Use of temporary names for newborns and associated
risks.
November 3, 2015
Adelman JS, Aschner JL, Schechter CB, et al. Use of Temporary Names for Newborns and Associated
Risks. Pediatrics. 2015;136(2):327-333. doi:10.1542/peds.2015-0007.
https://psnet.ahrq.gov/issue/use-temporary-names-newborns-and-associated-ris…