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psnet.ahrq.gov/node/74276/psn-pdf
January 19, 2022 - Guideline for Prevention of Unintentionally Retained
Surgical Items.
January 19, 2022
Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6.
doi:10.1002/aorn.13579.
https://psnet.ahrq.gov/issue/guideline-prevention-unintentionally-retained-surgical-items
Retained su…
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psnet.ahrq.gov/node/38559/psn-pdf
June 16, 2009 - Regional surveillance of emergency-department visits for
outpatient adverse drug events.
June 16, 2009
Capuano A, Irpino A, Gallo M, et al. Regional surveillance of emergency-department visits for outpatient
adverse drug events. Eur J Clin Pharmacol. 2009;65(7):721-8. doi:10.1007/s00228-009-0641-8.
https://psnet.a…
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psnet.ahrq.gov/node/842431/psn-pdf
January 11, 2023 - Confronting racism in pediatric care.
January 11, 2023
Danielson B. Confronting racism in pediatric care. Health Affairs. 2022;41(11):1681-1685.
doi:10.1377/hlthaff.2022.01157.
https://psnet.ahrq.gov/issue/confronting-racism-pediatric-care
Racism is a patient safety issue that is gaining the increased attention ne…
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psnet.ahrq.gov/node/43118/psn-pdf
April 16, 2014 - NCPDP Recommendations and Guidance for
Standardizing the Dosing Designations on Prescription
Container Labels of Oral Liquid Medications Version 1.0.
April 16, 2014
Scottsdale, AZ: National Council for Prescription Drug Programs; March 2014.
https://psnet.ahrq.gov/issue/ncpdp-recommendations-and-guidance-standardi…
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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/42102/psn-pdf
April 03, 2013 - Enhancing electronic health record usability in pediatric
patient care: a scenario-based approach.
April 3, 2013
Patterson ES, Zhang J, Abbott P, et al. Enhancing electronic health record usability in pediatric patient
care: a scenario-based approach. Jt Comm J Qual Patient Saf. 2013;39(3):129-135.
https://psnet.a…
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psnet.ahrq.gov/node/42985/psn-pdf
February 26, 2014 - Confusion—specimen mix-up in dermatopathology and
measures to prevent and detect it.
February 26, 2014
Weyers W. Confusion-specimen mix-up in dermatopathology and measures to prevent and detect it.
Dermatol Pract Concept. 2014;4(1):27-42. doi:10.5826/dpc.0401a04.
https://psnet.ahrq.gov/issue/confusion-specimen-mix…
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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/46701/psn-pdf
December 20, 2017 - The other big drug problem: older people taking too many
pills.
December 20, 2017
Boodman SG. Washington Post. December 9, 2017.
https://psnet.ahrq.gov/issue/other-big-drug-problem-older-people-taking-too-many-pills
The prevalence of polypharmacy among older patients represents an important concern for health care…
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psnet.ahrq.gov/node/44944/psn-pdf
July 01, 2016 - Managing and mitigating conflict in healthcare teams: an
integrative review.
July 1, 2016
Almost J, Wolff AC, Stewart-Pyne A, et al. Managing and mitigating conflict in healthcare teams: an
integrative review. J Adv Nurs. 2016;72(7):1490-505. doi:10.1111/jan.12903.
https://psnet.ahrq.gov/issue/managing-and-mitigat…
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psnet.ahrq.gov/node/41296/psn-pdf
April 11, 2012 - I-PASS, a mnemonic to standardize verbal handoffs.
April 11, 2012
Starmer AJ, Spector ND, Srivastava R, et al. I-pass, a mnemonic to standardize verbal handoffs.
Pediatrics. 2012;129(2):201-4. doi:10.1542/peds.2011-2966.
https://psnet.ahrq.gov/issue/i-pass-mnemonic-standardize-verbal-handoffs
Poor communication at…
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psnet.ahrq.gov/node/838638/psn-pdf
September 01, 2012 - Directed peer review in surgical pathology.
September 1, 2012
Smith ML, Raab SS. Directed peer review in surgical pathology. Adv Anat Pathol. 2012;19(5):331-337.
doi:10.1097/pap.0b013e31826661b7.
https://psnet.ahrq.gov/issue/directed-peer-review-surgical-pathology
Diagnostic error in pathology can result in delaye…
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psnet.ahrq.gov/node/38276/psn-pdf
December 10, 2008 - Addressing delays in medication administration for
patients transferred from the hospital to the nursing
home: a pilot quality improvement project.
December 10, 2008
Ward KT, Bates-Jensen B, Eslami MS, et al. Addressing delays in medication administration for patients
transferred from the hospital to the nursing h…
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psnet.ahrq.gov/node/36664/psn-pdf
May 27, 2011 - A prospective hazard and improvement analytic approach
to predicting the effectiveness of medication error
interventions.
May 27, 2011
Karnon J, McIntosh A, Dean JE, et al. A prospective hazard and improvement analytic approach to
predicting the effectiveness of medication error interventions. Saf Sci. 2006;45(4).…
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psnet.ahrq.gov/node/35470/psn-pdf
July 10, 2008 - Prevention of fall-related injuries in long-term care: a
randomized controlled trial of staff education.
July 10, 2008
Ray WA, Taylor JA, Brown AK, et al. Prevention of fall-related injuries in long-term care: a randomized
controlled trial of staff education. Arch Intern Med. 2005;165(19):2293-8.
https://psnet.ahr…
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psnet.ahrq.gov/node/38925/psn-pdf
September 16, 2009 - A literature review of the individual and systems factors
that contribute to medication errors in nursing practice.
September 16, 2009
Brady A-M, Malone A-M, Fleming S. A literature review of the individual and systems factors that contribute
to medication errors in nursing practice. J Nurs Manag. 2009;17(6):679-97…
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psnet.ahrq.gov/node/40992/psn-pdf
December 15, 2011 - Should patients get direct access to their laboratory test
results?: An answer with many questions.
December 15, 2011
Giardina TD, Singh H. Should patients get direct access to their laboratory test results? An answer with
many questions. JAMA. 2011;306(22):2502-2503. doi:10.1001/jama.2011.1797.
https://psnet.ahrq…
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psnet.ahrq.gov/node/43394/psn-pdf
July 30, 2014 - With oral chemotherapy, we simply must do better!
July 30, 2014
ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4.
https://psnet.ahrq.gov/issue/oral-chemotherapy-we-simply-must-do-better
To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter
…
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psnet.ahrq.gov/node/41378/psn-pdf
March 04, 2015 - Clinically missed cancer: how effectively can radiologists
use computer-aided detection?
March 4, 2015
Nishikawa RM, Schmidt RA, Linver MN, et al. Clinically Missed Cancer: How Effectively Can Radiologists
Use Computer-Aided Detection? American Journal of Roentgenology. 2012;198(3).
doi:10.2214/ajr.11.6423.
https…
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psnet.ahrq.gov/node/60192/psn-pdf
April 01, 2020 - Effective Reporting Could Improve Safe Use of Electronic
Health Records.
April 1, 2020
Philadelphia, PA: Pew Charitable Trusts; March 2020.
https://psnet.ahrq.gov/issue/effective-reporting-could-improve-safe-use-electronic-health-records
Electronic health records both enhance and challenge the safety of care proce…