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psnet.ahrq.gov/node/50940/psn-pdf
February 26, 2020 - The effect of smartphone-based application learning on
the nursing students' performance in preventing
medication errors in the pediatric units.
February 26, 2020
Pourteimour S, Hemmati MalsakPak M, Jasemi M, et al. The effect of smartphone-based application
learning on the nursing students' performance in prevent…
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psnet.ahrq.gov/node/838916/psn-pdf
October 26, 2022 - Falling through the cracks: the invisible hospital cleaning
workforce.
October 26, 2022
Hacker CE, Debono D, Travaglia J, et al. Falling through the cracks: the invisible hospital cleaning
workforce. J Health Organ Manag. 2022;36(8):981-986. doi:10.1108/jhom-02-2022-0035.
https://psnet.ahrq.gov/issue/falling-throu…
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psnet.ahrq.gov/node/37671/psn-pdf
July 25, 2008 - Improving transfusion safety: implementation of a
comprehensive computerized bar code-based tracking
system for detecting and preventing errors.
July 25, 2008
Askeland RW, McGrane S, Levitt JS, et al. Improving transfusion safety: implementation of a
comprehensive computerized bar code-based tracking system for de…
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psnet.ahrq.gov/node/44830/psn-pdf
January 01, 2019 - Tune-in and time-out: toward surgeon-led prevention of
"never" events.
February 17, 2016
Jones N. Tune-In and Time-Out: Toward Surgeon-Led Prevention of "Never" Events. J Patient Saf.
2019;15(4):e36-e39. doi:10.1097/PTS.0000000000000259.
https://psnet.ahrq.gov/issue/tune-and-time-out-toward-surgeon-led-prevention-…
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psnet.ahrq.gov/node/43733/psn-pdf
March 14, 2016 - The effect of an electronic checklist on critical care
provider workload, errors, and performance.
March 14, 2016
Thongprayoon C, Harrison AM, O'Horo JC, et al. The Effect of an Electronic Checklist on Critical Care
Provider Workload, Errors, and Performance. J Intensive Care Med. 2016;31(3):205-12.
doi:10.1177/08…
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psnet.ahrq.gov/node/46837/psn-pdf
March 21, 2018 - Drug shortages: effect on parenteral nutrition therapy.
March 21, 2018
Holcombe B, Mattox TW, Plogsted S. Drug Shortages: Effect on Parenteral Nutrition Therapy. Nutr Clin
Pract. 2018;33(1):53-61. doi:10.1002/ncp.10052.
https://psnet.ahrq.gov/issue/drug-shortages-effect-parenteral-nutrition-therapy
Shortages of me…
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psnet.ahrq.gov/node/45514/psn-pdf
November 02, 2016 - Building a culture of safety in ophthalmology.
November 2, 2016
Custer PL, Fitzgerald ME, Herman DC, et al. Building a Culture of Safety in Ophthalmology.
Ophthalmology. 2016;123(9 Suppl):S40-5. doi:10.1016/j.ophtha.2016.06.019.
https://psnet.ahrq.gov/issue/building-culture-safety-ophthalmology
Efforts to reduce m…
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psnet.ahrq.gov/node/46789/psn-pdf
March 20, 2018 - Healthcare professionals' views of smart glasses in
intensive care: a qualitative study.
March 20, 2018
Romare C, Hass U, Skär L. Healthcare professionals' views of smart glasses in intensive care: A qualitative
study. Intensive Crit Care Nurs. 2018;45:66-71. doi:10.1016/j.iccn.2017.11.006.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/41017/psn-pdf
February 01, 2013 - Safe surgery: how accurate are we at predicting intra-
operative blood loss?
February 1, 2013
Solon JG, Egan C, McNamara DA. Safe surgery: how accurate are we at predicting intra-operative blood
loss? J Eval Clin Pract. 2013;19(1):100-5. doi:10.1111/j.1365-2753.2011.01779.x.
https://psnet.ahrq.gov/issue/safe-surge…
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psnet.ahrq.gov/node/74128/psn-pdf
December 01, 2021 - Call to action: addressing pediatric fall safety in
ambulatory environments.
December 1, 2021
Benning S, Wolfe R, Banes M, et al. Call to action: addressing pediatric fall safety in ambulatory
environments. J Pediatr Nurs. 2021;61:372-377. doi:10.1016/j.pedn.2021.09.012.
https://psnet.ahrq.gov/issue/call-action-ad…
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psnet.ahrq.gov/node/41577/psn-pdf
September 27, 2016 - Nursing perception of the impact of medication carts on
patient safety and ergonomics in a teaching health care
center.
September 27, 2016
Rochais E, Atkinson S, Bussières J-F. Nursing perception of the impact of medication carts on patient
safety and ergonomics in a teaching health care center. J Pharm Pract. 201…
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psnet.ahrq.gov/node/39789/psn-pdf
August 25, 2010 - Using evidence, rigorous measurement, and collaboration
to eliminate central catheter-associated bloodstream
infections.
August 25, 2010
Sawyer M, Weeks K, Goeschel CA, et al. Using evidence, rigorous measurement, and collaboration to
eliminate central catheter-associated bloodstream infections. Crit Care Med. 201…
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psnet.ahrq.gov/node/838196/psn-pdf
July 01, 2019 - The impact of racism on child and adolescent health.
July 1, 2019
Trent M, Dooley DG, Dougé J, et al. The impact of racism on child and adolescent health. Pediatrics.
2019;144(2):e20191765. doi:10.1542/peds.2019-1765.
https://psnet.ahrq.gov/issue/impact-racism-child-and-adolescent-health
Children and adolescents a…
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psnet.ahrq.gov/node/72535/psn-pdf
December 02, 2020 - Learning from influenza vaccine errors to prepare for
COVID-19 vaccination campaigns.
December 2, 2020
ISMP Medication Safety Alert! Acute care edition. November 19, 2020;25(23):1-6.
https://psnet.ahrq.gov/issue/learning-influenza-vaccine-errors-prepare-covid-19-vaccination-campaigns
Safety professionals enco…
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psnet.ahrq.gov/node/47645/psn-pdf
April 17, 2019 - When a nurse is prosecuted for a fatal medical mistake,
does it make medicine safer?
April 17, 2019
Gordon M. Health Shots. National Public Radio. April 10, 2019.
https://psnet.ahrq.gov/issue/when-nurse-prosecuted-fatal-medical-mistake-does-it-make-medicine-safer
Punitive responses to medical errors persist despit…
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psnet.ahrq.gov/node/45923/psn-pdf
April 19, 2017 - Huddles and debriefings: improving communication on
labor and delivery.
April 19, 2017
McQuaid-Hanson E, Pian-Smith MCM. Huddles and Debriefings: Improving Communication on Labor and
Delivery. Anesthesiol Clin. 2017;35(1):59-67. doi:10.1016/j.anclin.2016.09.006.
https://psnet.ahrq.gov/issue/huddles-and-debriefings…
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psnet.ahrq.gov/node/34808/psn-pdf
February 18, 2011 - The high cost of low-frequency events: the anatomy and
economics of surgical mishaps.
February 18, 2011
Couch NP, Tilney NL, Rayner AA, et al. The high cost of low-frequency events: the anatomy and
economics of surgical mishaps. N Engl J Med. 1981;304(11):634-7.
https://psnet.ahrq.gov/issue/high-cost-low-frequency…
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psnet.ahrq.gov/node/45682/psn-pdf
November 01, 2017 - Changing smart pump vendors: lessons learned.
November 1, 2017
Arthur KJ, Catlin AC, Quebe A, et al. Changing Smart Pump Vendors: Lessons Learned. Hosp Pharm.
2016;51(9):782-789.
https://psnet.ahrq.gov/issue/changing-smart-pump-vendors-lessons-learned
Changes in processes, devices, and technologies can increase ri…
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psnet.ahrq.gov/node/50666/psn-pdf
November 13, 2019 - Over-the-top risky: overuse of ADC overrides, removal of
drugs without an order, and use of non-profiled cabinets.
November 13, 2019
ISMP Medication Safety Alert! Acute Care Edition. October 24, 2019.
https://psnet.ahrq.gov/issue/over-top-risky-overuse-adc-overrides-removal-drugs-without-order-and-use-
non-profile…
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psnet.ahrq.gov/node/44410/psn-pdf
August 12, 2015 - Workarounds in the workplace: a second look.
August 12, 2015
Seaman JB, Erlen JA. Workarounds in the Workplace: A Second Look. Orthop Nurs. 2015;34(4):235-242.
doi:10.1097/NOR.0000000000000161.
https://psnet.ahrq.gov/issue/workarounds-workplace-second-look
Workarounds are prevalent in health care and create opport…