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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/73477/psn-pdf
July 07, 2021 - Closing Death’s Door: Legal Innovations to End the
Epidemic of Healthcare Harm.
July 7, 2021
Saks M, Landsman S. New York, NY: Oxford University Press; 2021. ISBN: 9780190667986.
https://psnet.ahrq.gov/issue/closing-deaths-door-legal-innovations-end-epidemic-healthcare-harm
A weave of systemic factors c…
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psnet.ahrq.gov/node/863223/psn-pdf
February 28, 2024 - Prioritizing Patient Safety Through Quality Measurement.
February 28, 2024
Centers for Medicare & Medicaid Services, March 6 and 21, 2024.
https://psnet.ahrq.gov/issue/prioritizing-patient-safety-through-quality-measurement
Quality measurement intersects with patient safety and care improvement efforts to…
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psnet.ahrq.gov/node/44152/psn-pdf
November 06, 2015 - Infection Prevention.
November 6, 2015
Allen G, ed. AORN J. 2015;101:505-596.
https://psnet.ahrq.gov/issue/infection-prevention
A primary concern in the perioperative setting is the prevention of health care–associated infections,
particularly surgical site infections. Articles in this special issue explore strate…
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psnet.ahrq.gov/node/50809/psn-pdf
January 15, 2020 - Electronic Health Record (EHR) Safety and Usability: See
What We Mean.
January 15, 2020
MedStar Health National Center for Human Factors in Healthcare.
https://psnet.ahrq.gov/issue/electronic-health-record-ehr-safety-and-usability-see-what-we-mean
Electronic health records (EHR) optimize information functions in c…
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psnet.ahrq.gov/node/43234/psn-pdf
June 04, 2014 - Independent double-checks for high-alert medications:
essential practice.
June 4, 2014
Baldwin K, Walsh V. Independent double-checks for high-alert medications: essential practice. Nursing
(Brux). 2014;44(4):65-7. doi:10.1097/01.NURSE.0000444547.64972.dc.
https://psnet.ahrq.gov/issue/independent-double-checks-high…
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psnet.ahrq.gov/node/38420/psn-pdf
February 18, 2009 - Effect of short-term pretrial practice on surgical
proficiency in simulated environments: a randomized trial
of the "preoperative warm-up" effect.
February 18, 2009
Kahol K, Satava RM, Ferrara JJ, et al. Effect of Short-Term Pretrial Practice on Surgical Proficiency in
Simulated Environments: A Randomized Trial of…
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psnet.ahrq.gov/node/45386/psn-pdf
November 23, 2016 - Balancing doctor egos and errors.
November 23, 2016
Sweeney JF. Medical Economics. November 10, 2016.
https://psnet.ahrq.gov/issue/balancing-doctor-egos-and-errors
Disclosure and candor with patients after a medical error has gained support from organizations, clinicians,
and patients. This magazine article discus…
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psnet.ahrq.gov/node/73225/psn-pdf
May 05, 2021 - Black or 'other'? Doctors may be relying on race to make
decisions about your health.
May 5, 2021
Smith J, Spodak C. CNN. April 25, 2021.
https://psnet.ahrq.gov/issue/black-or-other-doctors-may-be-relying-race-make-decisions-about-your-health
Race-adjusted decision making tools perpetuate the potential for diagnos…
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psnet.ahrq.gov/node/46081/psn-pdf
April 19, 2017 - Why are medical errors still a leading cause of death?
April 19, 2017
Headley M.
https://psnet.ahrq.gov/issue/why-are-medical-errors-still-leading-cause-death
This magazine article explores the need for robust research and effective reporting to better understand the
prevalence of medical errors and how to prevent…
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psnet.ahrq.gov/node/47320/psn-pdf
September 05, 2018 - Patient safety climate: a study of Southern California
healthcare organizations.
September 5, 2018
Avramchuk AS, McGuire SJJ. Patient Safety Climate: A Study of Southern California Healthcare
Organizations. J Healthc Manag. 2018;63(3):175-192. doi:10.1097/JHM-D-16-00004.
https://psnet.ahrq.gov/issue/patient-safety…
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psnet.ahrq.gov/node/848044/psn-pdf
April 26, 2023 - Effect of a hospital command centre on patient safety: an
interrupted time series study.
April 26, 2023
Mebrahtu TF, McInerney CD, Benn J, et al. BMJ Health Care Inform. 2023;30(1):e100653.
https://psnet.ahrq.gov/issue/effect-hospital-command-centre-patient-safety-interrupted-time-series-study
Command centers…
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psnet.ahrq.gov/node/43763/psn-pdf
April 22, 2015 - The nurse's role in medication safety.
April 22, 2015
Durham B. The nurse's role in medication safety. Nursing (Brux). 2015;45(4).
doi:10.1097/01.NURSE.0000461850.24153.8b.
https://psnet.ahrq.gov/issue/nurses-role-medication-safety-0
Nurses perform a critical role in preventing medication errors. This commentary e…
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psnet.ahrq.gov/node/47112/psn-pdf
May 09, 2018 - 34 ways to survive your next trip to the hospital.
May 9, 2018
Crouch M. Reader's Digest. April 2018.
https://psnet.ahrq.gov/issue/34-ways-survive-your-next-trip-hospital
Involving patients in their care can help improve safety. This magazine article provides 34 tips from leading
patient safety experts to assist p…
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psnet.ahrq.gov/node/43270/psn-pdf
June 18, 2014 - Group urges going metric to head off dosing mistakes.
June 18, 2014
Budnitz DS, Lovegrove MC, Rose KO. Adherence to Label and Device Recommendations for Over-the-
Counter Pediatric Liquid Medications. PEDIATRICS. 2014;133(2). doi:10.1542/peds.2013-2362.
https://psnet.ahrq.gov/issue/group-urges-going-metric-head-dos…
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psnet.ahrq.gov/node/46341/psn-pdf
August 16, 2017 - In treating sepsis, questions about timing and mandates.
August 16, 2017
Abbasi J. In Treating Sepsis, Questions About Timing and Mandates. JAMA. 2017;318(6):506-508.
doi:10.1001/jama.2017.7997.
https://psnet.ahrq.gov/issue/treating-sepsis-questions-about-timing-and-mandates
Delayed treatment of sepsis can result …
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psnet.ahrq.gov/node/45586/psn-pdf
November 02, 2016 - Antimicrobial stewardship and patient safety.
November 2, 2016
Zukowski CM. Antimicrobial Stewardship and Patient Safety. AORN J. 2016;104(4):354-356.
doi:10.1016/j.aorn.2016.08.002.
https://psnet.ahrq.gov/issue/antimicrobial-stewardship-and-patient-safety
Antimicrobial stewardship has been highlighted as a strate…
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psnet.ahrq.gov/node/47386/psn-pdf
September 19, 2018 - Active-shooter response at a health care facility.
September 19, 2018
Inaba K, Eastman AL, Jacobs LM, et al. Active-Shooter Response at a Health Care Facility. N Engl J Med.
2018;379(6):583-586. doi:10.1056/NEJMms1800582.
https://psnet.ahrq.gov/issue/active-shooter-response-health-care-facility
Physical and verbal…
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psnet.ahrq.gov/node/39265/psn-pdf
February 03, 2010 - Intensive care unit alarms—how many do we need?
February 3, 2010
Siebig S, Kuhls S, Imhoff M, et al. Intensive care unit alarms--how many do we need? Crit Care Med.
2010;38(2):451-6. doi:10.1097/CCM.0b013e3181cb0888.
https://psnet.ahrq.gov/issue/intensive-care-unit-alarms-how-many-do-we-need
This study found that …
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psnet.ahrq.gov/node/44488/psn-pdf
September 16, 2015 - Environmental Cleaning for the Prevention of Healthcare-
Associated Infections (HAIs).
September 16, 2015
Leas BF, Sullivan N, Han JH, Pegues DA, Kaczmarek JL, Umscheid CA. Rockville, MD: Agency for
Healthcare Research and Quality; August 2015. Technical Brief No. 22. AHRQ Publication No. 15-
EHC020-EF.
https://p…