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psnet.ahrq.gov/node/846449/psn-pdf
March 22, 2023 - Healthcare professionals' perception of safety culture and
the Operating Room (OR) Black Box technology before
clinical implementation: a cross-sectional survey.
March 22, 2023
Strandbygaard J, Dose N, Moeller KE, et al. Healthcare professionals’ perception of safety culture and the
Operating Room (OR) Black Box t…
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psnet.ahrq.gov/node/48143/psn-pdf
January 01, 2020 - Assessing the safety of electronic health records: a
national longitudinal study of medication-related decision
support.
August 7, 2019
Holmgren J, Co Z, Newmark L, et al. Assessing the safety of electronic health records: a national
longitudinal study of medication-related decision support. BMJ Qual Saf. 2020;29(…
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psnet.ahrq.gov/node/40040/psn-pdf
December 21, 2014 - Patient education to prevent falls among older hospital
inpatients: a randomized controlled trial.
December 21, 2014
Haines TP, Hill A-M, Hill KD, et al. Patient education to prevent falls among older hospital inpatients: a
randomized controlled trial. Arch Intern Med. 2011;171(6):516-24. doi:10.1001/archinternmed.…
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psnet.ahrq.gov/node/857444/psn-pdf
December 06, 2023 - The relationship between nursing home staffing and
resident safety outcomes: a systematic review of reviews.
December 6, 2023
Blatter C, Osi?ska M, Simon M, et al. The relationship between nursing home staffing and resident safety
outcomes: a systematic review of reviews. Int J Nurs Stud. 2023;150:104641.
doi:10.1…
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psnet.ahrq.gov/node/867233/psn-pdf
December 04, 2024 - Evaluation of a natural language processing approach to
identify diagnostic errors and analysis of safety learning
system case review data: retrospective cohort study.
December 4, 2024
Tabaie A, Tran A, Calabria T, et al. Evaluation of a natural language processing approach to identify
diagnostic errors and analys…
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psnet.ahrq.gov/node/50751/psn-pdf
December 18, 2019 - Using a machine learning system to identify and prevent
medication prescribing errors: a clinical and cost analysis
evaluation.
December 18, 2019
Rozenblum R, Rodriguez-Monguio R, Volk LA, et al. Using a machine learning system to identify and
prevent medication prescribing errors: A clinical and cost analysis eva…
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psnet.ahrq.gov/node/37923/psn-pdf
July 23, 2008 - Unit-based clinical pharmacists' prevention of serious
medication errors in pediatric inpatients.
July 23, 2008
Kaushal R, Bates DW, Abramson EL, et al. Unit-based clinical pharmacists' prevention of serious
medication errors in pediatric inpatients. Am J Health-Syst Pharm. 2008;65(13):1254-1260.
doi:10.2146/ajhp0…
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psnet.ahrq.gov/node/60579/psn-pdf
June 10, 2020 - Outbreak investigation of COVID-19 among residents and
staff of an independent and assisted living community for
older adults in Seattle, Washington.
June 10, 2020
Roxby AC, Greninger AL, Hatfield KM, et al. Outbreak investigation of COVID-19 among residents and staff
of an independent and assisted living communit…
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psnet.ahrq.gov/node/37534/psn-pdf
February 13, 2008 - Measurable outcomes of quality improvement in the
trauma intensive care unit: the impact of a daily quality
rounding checklist.
February 13, 2008
DuBose JJ, Inaba K, Shiflett A, et al. Measurable outcomes of quality improvement in the trauma intensive
care unit: the impact of a daily quality rounding checklist. J …
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psnet.ahrq.gov/node/60642/psn-pdf
July 01, 2020 - Opioid prescribing after childbirth and risk for serious
opioid-related events: a cohort study.
July 1, 2020
Osmundson SS, Min JY, Wiese AD, et al. Opioid Prescribing After Childbirth and Risk for Serious Opioid-
Related Events: A Cohort Study. Ann Intern Med. 2020;173(5):412-414. doi:10.7326/m19-3805.
https://psn…
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psnet.ahrq.gov/node/836953/psn-pdf
April 20, 2022 - Systems-level factors affecting registered nurses during
care of women in labor experiencing clinical deterioration.
April 20, 2022
Bernstein SL, Catchpole K, Kelechi TJ, et al. Systems-level factors affecting registered nurses during care
of women in labor experiencing clinical deterioration. Jt Comm J Qual Patien…
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psnet.ahrq.gov/node/61099/psn-pdf
November 04, 2020 - Twelve-month review of infusion pump near-miss
medication and dose selection errors and user-initiated
"good save" corrections: retrospective study.
November 4, 2020
Waterson J, Al-Jaber R, Kassab T, et al. Twelve-month review of infusion pump near-miss medication and
dose selection errors and user-Initiated "good…
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psnet.ahrq.gov/node/849319/psn-pdf
May 24, 2023 - Attitudes of clinicians and patient safety culture before
and after the ARRIVE trial.
May 24, 2023
White VanGompel E, Carlock F, Singh L, et al. Attitudes of clinicians and patient safety culture before and
after the ARRIVE trial. J Obstet Gynecol Neonatal Nurs. 2023;52(3):211-222.
doi:10.1016/j.jogn.2022.12.007.
…
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psnet.ahrq.gov/innovation/handshake-antimicrobial-stewardship-model-recognize-and-prevent-diagnostic-errors
September 08, 2021 - EMERGING INNOVATIONS
Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors
Citation Text:
Searns JB, Williams MC, MacBrayne CE, et al. Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors. Diagnosis (Berl). 2020;8(3):347-352.…
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psnet.ahrq.gov/node/33604/psn-pdf
December 15, 2024 - Pharmacist's Role in Medication Safety
December 15, 2024
The Pharmacist's Role in Medication Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/pharmacists-role-medication-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current res…
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psnet.ahrq.gov/node/49778/psn-pdf
December 01, 2016 - One Dose, Two Errors
December 1, 2016
Filice GA. One Dose, Two Errors. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/one-dose-two-errors
The Case
A 65-year-old woman was admitted to the intensive care unit (ICU) with severe sepsis and respiratory
failure secondary to community-acquired pneumonia. The pati…
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psnet.ahrq.gov/node/49481/psn-pdf
May 01, 2005 - Discharge Against Medical Advice
May 1, 2005
Hwang SW. Discharge Against Medical Advice. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/discharge-against-medical-advice
The Case
A 50-year-old man with a history of alcohol abuse and alcohol-induced dementia was admitted to the
medical service with mild alco…
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psnet.ahrq.gov/node/49489/psn-pdf
September 01, 2005 - Double Trouble
September 1, 2005
Gurwitz JH. Double Trouble. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/double-trouble
Case Objectives
Appreciate the incidence of adverse drug events in older persons
List preventative measures that can be used to minimize medication errors in this population
Encourage…
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psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
June 15, 2024 - Inpatient Transitions of Care: Challenges and Safety Practices
Citation Text:
Satake A, McElroy V. Inpatient Transitions of Care: Challenges and Safety Practices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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…
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psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
March 26, 2015 - Right Place, Right Drug, Wrong Strength
Citation Text:
Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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