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psnet.ahrq.gov/node/41131/psn-pdf
February 15, 2012 - Effects of two commercial electronic prescribing systems
on prescribing error rates in hospital in-patients: a before
and after study.
February 15, 2012
Westbrook JI, Reckmann MH, Li L, et al. Effects of two commercial electronic prescribing systems on
prescribing error rates in hospital in-patients: a before and …
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psnet.ahrq.gov/node/41847/psn-pdf
November 28, 2012 - Improving organizational climate for quality and quality of
care: does membership in a collaborative help?
November 28, 2012
Nembhard IM, Northrup V, Shaller D, et al. Improving organizational climate for quality and quality of care:
does membership in a collaborative help? Med Care. 2012;50 Suppl:S74-82.
doi:10.1…
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psnet.ahrq.gov/node/43965/psn-pdf
July 16, 2015 - Decision making in trauma settings: simulation to
improve diagnostic skills.
July 16, 2015
Murray DJ, Freeman BD, Boulet JR, et al. Decision making in trauma settings: simulation to improve
diagnostic skills. Simul Healthc. 2015;10(3):139-145. doi:10.1097/SIH.0000000000000073.
https://psnet.ahrq.gov/issue/decision…
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psnet.ahrq.gov/node/41597/psn-pdf
December 02, 2014 - Medical errors in US pediatric inpatients with chronic
conditions.
December 2, 2014
Ahuja N, Zhao W, Xiang H. Medical errors in US pediatric inpatients with chronic conditions. Pediatrics.
2012;130(4):e786-e793. doi:10.1542/peds.2011-2555.
https://psnet.ahrq.gov/issue/medical-errors-us-pediatric-inpatients-chronic…
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psnet.ahrq.gov/node/40993/psn-pdf
December 14, 2011 - Anticoagulation-associated adverse drug events.
December 14, 2011
Piazza G, Nguyen TN, Cios D, et al. Anticoagulation-associated Adverse Drug Events. Am J Med.
2011;124(12). doi:10.1016/j.amjmed.2011.06.009.
https://psnet.ahrq.gov/issue/anticoagulation-associated-adverse-drug-events
Warfarin and other anticoagulan…
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psnet.ahrq.gov/node/45894/psn-pdf
June 23, 2017 - Tell me how pleased you are with your workplace, and I
will tell you how often you wash your hands.
June 23, 2017
Sholomovich L, Magnezi R. Tell me how pleased you are with your workplace, and I will tell you how often
you wash your hands. Am J Infect Control. 2017;45(6):677-681. doi:10.1016/j.ajic.2016.12.005.
ht…
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psnet.ahrq.gov/node/38891/psn-pdf
January 04, 2010 - Do calculation errors by nurses cause medication errors
in clinical practice? A literature review.
January 4, 2010
Wright K. Do calculation errors by nurses cause medication errors in clinical practice? A literature review.
Nurse Educ Today. 2010;30(1):85-97. doi:10.1016/j.nedt.2009.06.009.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/38047/psn-pdf
January 31, 2011 - Single-patient rooms for safe patient-centered hospitals.
January 31, 2011
Detsky ME. Single-Patient Rooms for Safe Patient-Centered Hospitals. JAMA. 2008;300(8).
doi:10.1001/jama.300.8.954.
https://psnet.ahrq.gov/issue/single-patient-rooms-safe-patient-centered-hospitals
Providing patient-centered care continues …
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psnet.ahrq.gov/node/39673/psn-pdf
December 21, 2014 - Effect of hospital follow-up appointment on clinical event
outcomes and mortality.
December 21, 2014
Grafft CA, McDonald FS, Ruud KL, et al. Effect of hospital follow-up appointment on clinical event
outcomes and mortality. Arch Intern Med. 2010;170(11):955-60. doi:10.1001/archinternmed.2010.105.
https://psnet.ahr…
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psnet.ahrq.gov/node/47113/psn-pdf
July 11, 2018 - The impact of pharmacists-led medicines reconciliation
on healthcare outcomes in secondary care: a systematic
review and meta-analysis of randomized controlled trials.
July 11, 2018
Cheema E, Alhomoud FK, Kinsara ASA-D, et al. The impact of pharmacists-led medicines reconciliation on
healthcare outcomes in seconda…
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psnet.ahrq.gov/node/73177/psn-pdf
April 28, 2021 - The association of nursing home characteristics and
quality with adverse events after a hospitalization.
April 28, 2021
Field TS, Fouayzi H, Crawford S, et al. The association of nursing home characteristics and quality with
adverse events after a hospitalization. J Am Med Dir Assoc. 2021;22(10):2196-2200.
doi:10.…
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psnet.ahrq.gov/node/35742/psn-pdf
July 15, 2010 - Physician evaluation after medical errors: does having a
computer decision aid help or hurt in hindsight?
July 15, 2010
Pezzo M, Pezzo SP. Physician evaluation after medical errors: does having a computer decision aid help
or hurt in hindsight? Med Decis Making. 2006;26(1):48-56.
https://psnet.ahrq.gov/issue/physi…
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psnet.ahrq.gov/node/46892/psn-pdf
June 13, 2018 - AHRQ National Scorecard on Hospital-Acquired
Conditions Updated Baseline Rates and Preliminary
Results 2014–2016.
June 13, 2018
Rockville, MD: Agency for Healthcare Research and Quality; June 2018.
https://psnet.ahrq.gov/issue/ahrq-national-scorecard-hospital-acquired-conditions-updated-baseline-rates-
and-prelim…
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psnet.ahrq.gov/node/74717/psn-pdf
February 02, 2022 - Improving hospital infant safe sleep compliance by using
safety prevention bundle methodology.
February 2, 2022
Batra EK, Lewis ML, Saravana D, et al. Improving hospital infant safe sleep compliance by using safety
prevention bundle methodology. Pediatrics. 2021;148(6):e2020033704. doi:10.1542/peds.2020-033704.
ht…
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psnet.ahrq.gov/node/38639/psn-pdf
May 20, 2009 - Eight CT lessons that we learned the hard way: an
analysis of current patterns of radiological error and
discrepancy with particular emphasis on CT.
May 20, 2009
McCreadie G, Oliver TB. Eight CT lessons that we learned the hard way: an analysis of current patterns of
radiological error and discrepancy with particu…
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psnet.ahrq.gov/node/844990/psn-pdf
February 22, 2023 - Shape matters: a neglected feature of medication safety:
why regulating the shape of medication containers can
improve medication safety.
February 22, 2023
Bitan Y, Nunnally M. Shape matters: a neglected feature of medication safety: why regulating the shape of
medication containers can improve medication safety. …
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psnet.ahrq.gov/node/866405/psn-pdf
July 31, 2024 - Analysis of an academic medical center’s corrective
action plan in response to fatal medication error using the
Institute for Safe Medication Practices’ Hierarchy of
Effectiveness.
July 31, 2024
Stolte AR, Siwy YM, Tanios SB, et al. Analysis of an academic medical center’s corrective action plan in
response to fa…
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psnet.ahrq.gov/node/844040/psn-pdf
February 08, 2023 - A customized triggers program: a children's hospital's
experience in improving trigger usability.
February 8, 2023
Reinhart RM, Safari-Ferra P, Badh R, et al. A customized triggers program: a children's hospital's
experience in improving trigger usability. Pediatrics. 2023;151(2):e2022056452. doi:10.1542/peds.2022-…
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psnet.ahrq.gov/node/44103/psn-pdf
July 08, 2015 - Results of survey on pediatric medication safety—part 1
and part 2.
July 8, 2015
ISMP Medication Safety Alert! Acute Care Edition. June 4, 2015;20:1-6. July 2, 2015;20:1-5.
https://psnet.ahrq.gov/issue/results-survey-pediatric-medication-safety-part-1-and-part-2
Hospitalized children are susceptible to medication …
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psnet.ahrq.gov/node/45225/psn-pdf
June 15, 2016 - A case of transfusion error in a trauma patient with
subsequent root cause analysis leading to institutional
change.
June 15, 2016
Clifford SP, Mick PB, Derhake BM. A case of transfusion error in a trauma patient with subsequent root
cause analysis leading to institutional change. J Investig Med High Impact Case R…