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psnet.ahrq.gov/node/837024/psn-pdf
May 04, 2022 - The potential for leveraging machine learning to filter
medication alerts.
May 4, 2022
Liu S, Kawamoto K, Del Fiol G, et al. The potential for leveraging machine learning to filter medication
alerts. J Am Med Inform Assoc. 2022;29(5):891-899. doi:10.1093/jamia/ocab292.
https://psnet.ahrq.gov/issue/potential-levera…
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psnet.ahrq.gov/node/73396/psn-pdf
June 16, 2021 - The impact of the built environment on patient falls in
hospital rooms: an integrative review.
June 16, 2021
Pati D, Valipoor S, Lorusso L, et al. The impact of the built environment on patient falls in hospital rooms:
an integrative review. J Patient Saf. 2021;17(4):273-281. doi:10.1097/pts.0000000000000613.
http…
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psnet.ahrq.gov/node/36106/psn-pdf
May 27, 2011 - Evidence-based red cell transfusion in the critically ill:
quality improvement using computerized physician order
entry.
May 27, 2011
Rana R, Afessa B, Keegan MT, et al. Evidence-based red cell transfusion in the critically ill: quality
improvement using computerized physician order entry. Crit Care Med. 2006;34(7…
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psnet.ahrq.gov/node/45986/psn-pdf
March 29, 2017 - Pediatric prehospital medication dosing errors: a national
survey of paramedics.
March 29, 2017
Hoyle JD, Crowe RP, Bentley MA, et al. Pediatric prehospital medication dosing errors: a national survey of
paramedics. Prehosp Emerg Care. 2017;21(2):185-191. doi:10.1080/10903127.2016.1227001.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/841492/psn-pdf
December 14, 2022 - Cybersecurity is Patient Safety: Policy Options in the
Health Care Sector.
December 14, 2022
Washington DC; Office of Senator Mark Warner: November 25, 2022.
https://psnet.ahrq.gov/issue/cybersecurity-patient-safety-policy-options-health-care-sector
There is lack of consensus concerning the need for increased syst…
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psnet.ahrq.gov/node/43677/psn-pdf
November 19, 2014 - Reporting and Learning Systems for Medication Errors:
The Role of Pharmacovigilance Centres.
November 19, 2014
Bencheikh SR, Cousins D, Benabdallah G, et al. Geneva, Switzerland: World Health Organization; October
2014. ISBN: 9789241507943.
https://psnet.ahrq.gov/issue/reporting-and-learning-systems-medication-err…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/index.html
September 01, 2021 - Long-term Care Facilities
Resources for long-term care facilities
Improving Patient Safety in Long-Term Care Facilities
Detecting and promptly reporting changes in a nursing home resident's condition are critical for ensuring the resident's well-being and safety. Such changes may represent a patient s…
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psnet.ahrq.gov/node/44473/psn-pdf
September 27, 2016 - Medication errors in hospitals: a literature review of
disruptions to nursing practice during medication
administration.
September 27, 2016
Hayes C, Jackson D, Davidson PM, et al. Medication errors in hospitals: a literature review of disruptions to
nursing practice during medication administration. J Clin Nurs. 2…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-n.docx
June 02, 2025 - AHRQ Safety Program for Reducing CAUTI in Hospitals
Appendix N. Skin Care in the Incontinent Patient
An indwelling urinary catheter is not the answer for urinary incontinence.
· Good skin care technique will prevent skin breakdown.
· Use perineal cleansing products as needed.
· Avoid use of agents containing alcoho…
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psnet.ahrq.gov/node/854252/psn-pdf
October 04, 2023 - Standardization and visualization of the surgical time-out.
October 4, 2023
Levy BE, Wilt WS, Lantz S, et al. Standardization and visualization of the surgical time-out. J Patient Saf.
2023;19(7):453-459. doi:10.1097/pts.0000000000001156.
https://psnet.ahrq.gov/issue/standardization-and-visualization-surgical-time-…
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psnet.ahrq.gov/node/37754/psn-pdf
May 14, 2008 - Potentially inappropriate medication use in hospitalized
elders.
May 14, 2008
Rothberg MB, Pekow PS, Liu F, et al. Potentially inappropriate medication use in hospitalized elders. J
Hosp Med. 2008;3(2):91-102. doi:10.1002/jhm.290.
https://psnet.ahrq.gov/issue/potentially-inappropriate-medication-use-hospitalized-e…
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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/73415/psn-pdf
June 23, 2021 - Patient safety in dermatology: a ten-year update.
June 23, 2021
Patel J, Otto E, Taylor JS, et al. Dermatol Online J. 2021;27(3).
https://psnet.ahrq.gov/issue/patient-safety-dermatology-ten-year-update
In an update to their 2010 article, this review’s authors summarized the patient safety literature in
dermatology…
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psnet.ahrq.gov/node/34870/psn-pdf
April 18, 2016 - Unintended medication discrepancies at the time of
hospital admission.
April 18, 2016
Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital
admission. Arch Intern Med. 2005;165(4):424-9.
https://psnet.ahrq.gov/issue/unintended-medication-discrepancies-time-hospita…
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psnet.ahrq.gov/node/44014/psn-pdf
March 20, 2019 - Patient Centered Medical Home Resource Center: Quality
and Safety.
March 20, 2019
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/patient-centered-medical-home-resource-center-quality-and-safety
The Patient Centered Medical Home (PCMH) concept reorganizes primary care services to ensure th…
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psnet.ahrq.gov/node/39597/psn-pdf
July 14, 2010 - Ten strategies to improve management of abnormal test
result alerts in the electronic health record.
July 14, 2010
Singh H, Wilson L, Reis B, et al. Ten strategies to improve management of abnormal test result alerts in the
electronic health record. J Patient Saf. 2010;6(2):121-123. doi:10.1097/PTS.0b013e3181ddf652…
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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/43701/psn-pdf
July 03, 2016 - Blink or think: can further reflection improve initial
diagnostic impressions?
July 3, 2016
Hess BJ, Lipner RS, Thompson V, et al. Blink or think: can further reflection improve initial diagnostic
impressions? Acad Med. 2015;90(1):112-118. doi:10.1097/ACM.0000000000000550.
https://psnet.ahrq.gov/issue/blink-or-thi…
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psnet.ahrq.gov/node/48001/psn-pdf
May 22, 2019 - Medicines safety in anaesthetic practice.
May 22, 2019
Mackay E, Jennings J, Webber S. Medicines safety in anaesthetic practice. BJA Edu. 2019;19(5):151-157.
doi:10.1016/j.bjae.2019.01.001.
https://psnet.ahrq.gov/issue/medicines-safety-anaesthetic-practice
Human factors affect medication delivery in the operating …
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psnet.ahrq.gov/node/45792/psn-pdf
December 20, 2017 - Reevaluation of diagnosis in adults with physician-
diagnosed asthma.
December 20, 2017
Aaron SD, Vandemheen KL, FitzGerald M, et al. Reevaluation of Diagnosis in Adults With Physician-
Diagnosed Asthma. JAMA. 2017;317(3):269-279. doi:10.1001/jama.2016.19627.
https://psnet.ahrq.gov/issue/reevaluation-diagnosis-adu…