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psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - excitability, and thereby mimicking the neurodepressant effect of alcohol. 12,13
• This mechanism reduces
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digital.ahrq.gov/principal-investigator/koppel-ross
January 01, 2023 - Koppel, Ross
Guide to reducing unintended consequences of electronic health records.
Citation
Jones SS, Koppel R, Ridgely MS, et al. Guide to reducing unintended consequences of electronic health records. (Prepared by RAND Corporation under Contract No. 290-06-0017-5). AHRQ Pu…
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psnet.ahrq.gov/node/845652/psn-pdf
March 14, 2023 - Controlled substance drug diversion by healthcare
workers as a threat to patient safety.
March 14, 2023
ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4):1-4; March 9, 2023:28(5):1-4.
https://psnet.ahrq.gov/issue/controlled-substance-drug-diversion-healthcare-workers-threat-patient-safety
D…
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psnet.ahrq.gov/node/73471/psn-pdf
July 07, 2021 - Rapid response teams as a patient safety practice for
failure to rescue.
July 7, 2021
Fischer CP, Bilimoria KY, Ghaferi AA. Rapid Response Teams as a Patient Safety Practice for Failure to
Rescue. JAMA. 2021;326(2):179-180. doi:10.1001/jama.2021.7510.
https://psnet.ahrq.gov/issue/rapid-response-teams-patient-safet…
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psnet.ahrq.gov/node/47331/psn-pdf
October 17, 2018 - Description and factors associated with missed nursing
care in an acute care community hospital.
October 17, 2018
Duffy JR, Culp S, Padrutt T. Description and factors associated with missed nursing care in an acute care
community hospital. J Nurs Adm. 2018;48(7-8):361-367. doi:10.1097/NNA.0000000000000630.
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psnet.ahrq.gov/node/851065/psn-pdf
June 28, 2023 - Patient safety of perioperative medication through the
lens of digital health and artificial intelligence.
June 28, 2023
Ye J. Patient safety of perioperative medication through the lens of digital health and artificial intelligence.
JMIR Periop Med. 2023;6:e34453. doi:10.2196/34453.
https://psnet.ahrq.gov/issue/p…
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psnet.ahrq.gov/node/47148/psn-pdf
June 25, 2018 - Necessity for a pathway for "high-alert" patients.
June 25, 2018
Shane R, Amer K, Noh L, et al. Necessity for a pathway for "high-alert" patients. Am J Health Syst Pharm.
2018;75(13):993-997. doi:10.2146/ajhp170397.
https://psnet.ahrq.gov/issue/necessity-pathway-high-alert-patients
Medication errors can contribute…
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psnet.ahrq.gov/node/838081/psn-pdf
September 14, 2022 - Medication dosage calculation among nursing students:
does digital technology make a difference? A literature
review.
September 14, 2022
Stake-Nilsson K, Almstedt M, Fransson G, et al. Medication dosage calculation among nursing students:
does digital technology make a difference? A literature review. BMC Nurs. 20…
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psnet.ahrq.gov/node/45650/psn-pdf
December 14, 2016 - Are physicians safely prescribing opioids for chronic
noncancer pain? A systematic review of current evidence.
December 14, 2016
Tournebize J, Gibaja V, Muszczak A, et al. Are Physicians Safely Prescribing Opioids for Chronic
Noncancer Pain? A Systematic Review of Current Evidence. Pain Pract. 2016;16(3):370-83.
d…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/148-investigating-defect-lfd-worksheet.docx
June 02, 2025 - AHRQ Safety Program for MRSA Prevention
Investigating A Defect Worksheet
ICU & Non-ICUTop Contributing Factors
Interventions To Reduce Risk
Who Will Do It and By When
Status
Enter contributing factor
Enter intervention
Enter responsible staff, deadline
Enter status
Enter contributing factor
Enter intervention
Enter re…
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psnet.ahrq.gov/node/73566/psn-pdf
August 04, 2021 - Personal formularies of primary care physicians across 4
health care systems.
August 4, 2021
Galanter W, Eguale T, Gellad WF, et al. Personal formularies of primary care physicians across 4 health
care systems. JAMA Netw Open. 2021;4(7):e2117038. doi:10.1001/jamanetworkopen.2021.17038.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/47783/psn-pdf
April 10, 2019 - An IDEA: safety training to improve critical thinking by
individuals and teams.
April 10, 2019
Browne AM, Deutsch ES, Corwin K, et al. An IDEA: Safety Training to Improve Critical Thinking by
Individuals and Teams. Am J Med Qual. 2019;34(6):569-576. doi:10.1177/1062860618820687.
https://psnet.ahrq.gov/issue/idea-s…
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psnet.ahrq.gov/node/47542/psn-pdf
January 16, 2019 - Utilizing a Systems and Design Thinking Approach for
Improving Well-Being Within Health Professional
Education and Health Care.
January 16, 2019
Kreitzer MJ, Carter K, Coffey DS, et al. NAM Perspectives. Washington, DC: National Academy of
Medicine; 2019.
https://psnet.ahrq.gov/issue/utilizing-systems-and-design-…
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psnet.ahrq.gov/node/837073/psn-pdf
May 11, 2022 - Clinical progress note: situation awareness for clinical
deterioration in hospitalized children.
May 11, 2022
Sosa T, Galligan MM, Brady PW. Clinical progress note: situation awareness for clinical deterioration in
hospitalized children. J Hosp Med. 2022;17(3):199-202. doi:10.1002/jhm.2774.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/40263/psn-pdf
March 02, 2011 - Trauma resuscitation errors and computer-assisted
decision support.
March 2, 2011
FitzGerald M, Cameron P, Mackenzie CF, et al. Trauma resuscitation errors and computer-assisted
decision support. Arch Surg. 2011;146(2):218-25. doi:10.1001/archsurg.2010.333.
https://psnet.ahrq.gov/issue/trauma-resuscitation-errors-…
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psnet.ahrq.gov/node/73530/psn-pdf
July 28, 2021 - The nature, severity and causes of medication incidents
from an Australian community pharmacy incident
reporting system: the QUMwatch study.
July 28, 2021
Adie K, Fois RA, McLachlan AJ, et al. The nature, severity and causes of medication incidents from an
Australian community pharmacy incident reporting system: T…
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psnet.ahrq.gov/node/46088/psn-pdf
May 24, 2017 - Innovative use of the electronic health record to support
harm reduction efforts.
May 24, 2017
Hyman D, Neiman J, Rannie M, et al. Innovative Use of the Electronic Health Record to Support Harm
Reduction Efforts. Pediatrics. 2017;139(5). doi:10.1542/peds.2015-3410.
https://psnet.ahrq.gov/issue/innovative-use-elect…
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psnet.ahrq.gov/node/47495/psn-pdf
October 31, 2018 - Developing and evaluating clinical leadership
interventions for frontline healthcare providers: a review
of the literature.
October 31, 2018
Mianda S, Voce A. Developing and evaluating clinical leadership interventions for frontline healthcare
providers: a review of the literature. BMC Health Serv Res. 2018;18(1):…
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psnet.ahrq.gov/node/36276/psn-pdf
October 21, 2010 - Effects of nursing rounds on patients' call light use,
satisfaction, and safety.
October 21, 2010
Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds: on patients' call light use, satisfaction, and
safety. Am J Nurs. 2006;106(9):58-71.
https://psnet.ahrq.gov/issue/effects-nursing-rounds-patients-call-light…
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psnet.ahrq.gov/node/47224/psn-pdf
June 27, 2018 - Managing Alarms in Acute Care Across the Life Span:
Electrocardiography and Pulse Oximetry.
June 27, 2018
Managing Alarms in Acute Care Across the Life Span: Electrocardiography and Pulse Oximetry. Crit Care
Nurse. 2018;38(2):e16-e20. doi:10.4037/ccn2018468.
https://psnet.ahrq.gov/issue/managing-alarms-acute-care-…