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psnet.ahrq.gov/node/847057/psn-pdf
April 05, 2023 - Implement strategies to prevent persistent medication
errors and hazards.
April 5, 2023
ISMP Medication Safety Alert! Acute care edition. March 23, 2023;28(6):1-4.
https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards
Medication mistakes are recognized contributors to p…
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psnet.ahrq.gov/node/844792/psn-pdf
January 01, 2020 - Surgical data recording technology: a solution to address
medical errors?
September 18, 2019
Shah NA, Jue J, Mackey T. Surgical Data Recording Technology. Ann Surg. 2020;271(3):431-433.
doi:10.1097/sla.0000000000003510.
https://psnet.ahrq.gov/issue/surgical-data-recording-technology-solution-address-medical-errors…
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psnet.ahrq.gov/node/836999/psn-pdf
April 27, 2022 - Toolkit for Preventing CLABSI and CAUTI in ICUs.
April 27, 2022
Rockville, MD: Agency for Healthcare Research and Quality; April 2022.
https://psnet.ahrq.gov/issue/toolkit-preventing-clabsi-and-cauti-icus
Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this
cu…
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psnet.ahrq.gov/node/45503/psn-pdf
October 29, 2017 - All CLEAR? Preparing for IT downtime.
October 29, 2017
Kashiwagi DT, Sexton MD, Graves ES, et al. All CLEAR? Preparing for IT Downtime. Am J Med Qual.
2017;32(5):547-551. doi:10.1177/1062860616667546.
https://psnet.ahrq.gov/issue/all-clear-preparing-it-downtime
Due to the increasing integration of health care proc…
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psnet.ahrq.gov/node/73606/psn-pdf
August 18, 2021 - Broadening the concept of patient safety culture through
value-based healthcare.
August 18, 2021
Dombrádi V, Bíró K, Jonitz G, et al. Broadening the concept of patient safety culture through value-based
healthcare. J Health Organ Manag. 2021;35(5):541-549. doi:10.1108/jhom-07-2020-0287.
https://psnet.ahrq.gov/issu…
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digital.ahrq.gov/organization/delta-health-alliance-inc
January 01, 2023 - Delta Health Alliance, Inc.
The Bettering Lives Utilizing Electronic Systems (BLUES) Project: Improving Diabetes Outcomes in Mississippi with Health Information Technology - 2011
Principal Investigator
Matthews, Karen
Project Name
The Bettering Lives Utilizing El…
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psnet.ahrq.gov/node/836864/psn-pdf
April 06, 2022 - Improving the specificity of drug-drug interaction alerts:
can it be done?
April 6, 2022
Reese T, Wright A, Liu S, et al. Improving the specificity of drug-drug interaction alerts: Can it be done? Am
J Health Syst Pharm. 2022;79(13):1086-1095. doi:10.1093/ajhp/zxac045.
https://psnet.ahrq.gov/issue/improving-specif…
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psnet.ahrq.gov/node/45910/psn-pdf
March 08, 2017 - Electronically Generated Medication Administration and
Electronic Medication Administration Records for the
Prevention of Medication Transcription Errors: Review of
Clinical Effectiveness and Safety.
March 8, 2017
Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2016.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/39615/psn-pdf
December 17, 2010 - Computerized decision support for medication dosing in
renal insufficiency: a randomized, controlled trial.
December 17, 2010
Terrell KM, Perkins AJ, Hui SL, et al. Computerized decision support for medication dosing in renal
insufficiency: a randomized, controlled trial. Ann Emerg Med. 2010;56(6):623-9.
doi:10.10…
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psnet.ahrq.gov/node/73971/psn-pdf
October 13, 2021 - Safety culture as a patient safety practice for alarm
fatigue.
October 13, 2021
Winters BD, Slota JM, Bilimoria KY. Safety culture as a patient safety practice for alarm fatigue. JAMA.
2021;326(12):1207-1208. doi:10.1001/jama.2021.8316.
https://psnet.ahrq.gov/issue/safety-culture-patient-safety-practice-alarm-fati…
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psnet.ahrq.gov/node/47954/psn-pdf
August 07, 2019 - Special Issue on Resilience Engineering and High
Reliability Organizations.
August 7, 2019
Wears RL, Roberts KH, eds. Safety Sci. 2019;117;458-533.
https://psnet.ahrq.gov/issue/special-issue-resilience-engineering-and-high-reliability-organizations
Resilience is an organizational characteristic that enables indivi…
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psnet.ahrq.gov/node/842432/psn-pdf
January 11, 2023 - Medication errors: the year in review: January through
December 2021.
January 11, 2023
Pharmacy Practice News Special Edition. December 13, 2022: 43-54.
https://psnet.ahrq.gov/issue/medication-errors-year-review-january-through-december-2021
Medication errors continue to occur despite long-standing efforts to redu…
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psnet.ahrq.gov/node/45801/psn-pdf
August 03, 2017 - Overcoming diagnostic errors in medical practice.
August 3, 2017
Bordini BJ, Stephany A, Kliegman RM. Overcoming Diagnostic Errors in Medical Practice. J Pediatr.
2017;185. doi:10.1016/j.jpeds.2017.02.065.
https://psnet.ahrq.gov/issue/overcoming-diagnostic-errors-medical-practice
This commentary describes a progra…
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psnet.ahrq.gov/node/48072/psn-pdf
June 19, 2019 - Independent double checks: worth the effort if used
judiciously and properly.
June 19, 2019
ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24:1-7.
https://psnet.ahrq.gov/issue/independent-double-checks-worth-effort-if-used-judiciously-and-properly
Independent double checks can reduce risk of human …
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psnet.ahrq.gov/node/48111/psn-pdf
July 10, 2019 - Medication Safety in Key Action Areas.
July 10, 2019
Geneva, Switzerland: World Health Organization; 2019.
https://psnet.ahrq.gov/issue/medication-safety-key-action-areas
Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores
key areas of concern that require act…
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psnet.ahrq.gov/node/42955/psn-pdf
May 11, 2016 - National Patient Safety Alerting System.
May 11, 2016
National Health Service England
https://psnet.ahrq.gov/issue/national-patient-safety-alerting-system
In response to the Francis report, this three-stage reporting system was launched to help National Health
Service organizations learn from incidents and incorpo…
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psnet.ahrq.gov/node/43331/psn-pdf
July 09, 2014 - Open wide: looking into the safety culture of dental
school clinics.
July 9, 2014
Ramoni R, Walji MF, Tavares A, et al. Open wide: looking into the safety culture of dental school clinics. J
Dent Edu. 2014;78(5):745-756.
https://psnet.ahrq.gov/issue/open-wide-looking-safety-culture-dental-school-clinics
Researche…
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psnet.ahrq.gov/node/44495/psn-pdf
September 30, 2015 - Impact of laws aimed at healthcare-associated infection
reduction: a qualitative study.
September 30, 2015
Stone PW, Pogorzelska-Maziarz M, Reagan J, et al. Impact of laws aimed at healthcare-associated
infection reduction: a qualitative study. BMJ Qual Saf. 2015;24(10):637-44. doi:10.1136/bmjqs-2014-
003921.
htt…
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psnet.ahrq.gov/node/47792/psn-pdf
May 01, 2019 - New evidence on stemming low-value prescribing.
May 1, 2019
Sacarny A, Barnett ML, Agrawal S. NEJM Catalyst. April 10, 2019.
https://psnet.ahrq.gov/issue/new-evidence-stemming-low-value-prescribing
Overprescribing contributes to polypharmacy, antibiotic resistance, and opioid misuse. This commentary
discusses stra…
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psnet.ahrq.gov/node/74143/psn-pdf
December 01, 2021 - Confronting Racism in Health Care: Moving from
Proclamations to New Practices.
December 1, 2021
Hostetter M, Klein S. New York, NY: Commonwealth Fund; October 18, 2021
https://psnet.ahrq.gov/issue/confronting-racism-health-care-moving-proclamations-new-practices
Structural racism affects the safety and equit…