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psnet.ahrq.gov/node/864383/psn-pdf
March 13, 2024 - Cyberattack on UnitedHealth still impacting prescription
access: "These are threats to life".
March 13, 2024
Sganga N, Triay A. CBS Evening News. February 29, 2024.
https://psnet.ahrq.gov/issue/cyberattack-unitedhealth-still-impacting-prescription-access-these-are-threats-
life
As health care becomes more technol…
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psnet.ahrq.gov/node/837593/psn-pdf
June 29, 2022 - Adverse event reporting priorities: an integrative review.
June 29, 2022
Falcone ML, Van Stee SK, Tokac U, et al. Adverse event reporting priorities: an integrative review. J
Patient Saf. 2022;18(4):e727-e740. doi:10.1097/pts.0000000000000945.
https://psnet.ahrq.gov/issue/adverse-event-reporting-priorities-integrat…
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psnet.ahrq.gov/node/35971/psn-pdf
May 27, 2011 - Effectiveness of computerized provider order entry with
dose range checking on prescribing errors.
May 27, 2011
Boling B, McKibben M, Hingl J, et al. Effectiveness of Computerized Provider Order Entry with Dose Range
Checking on Prescribing Errors. J Patient Saf. 2008;1(4). doi:10.1097/01.jps.0000215339.03807.fd.
…
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psnet.ahrq.gov/node/43758/psn-pdf
March 17, 2015 - A patient safety checklist for the cardiac catheterisation
laboratory.
March 17, 2015
Cahill TJ, Clarke SC, Simpson IA, et al. A patient safety checklist for the cardiac catheterisation laboratory.
Heart. 2015;101(2):91-3. doi:10.1136/heartjnl-2014-306927.
https://psnet.ahrq.gov/issue/patient-safety-checklist-card…
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psnet.ahrq.gov/node/34721/psn-pdf
November 19, 2015 - Preventing medical injury.
November 19, 2015
Leape LL, Lawthers AG, Brennan TA, et al. Preventing medical injury. QRB - Qual Rev Bull.
1993;19(5):144-149. doi:10.1016/s0097-5990(16)30608-x.
https://psnet.ahrq.gov/issue/preventing-medical-injury
Reviewing cases of medical error in the Harvard Medical Practice Study…
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psnet.ahrq.gov/node/46681/psn-pdf
April 16, 2018 - Trainee autonomy and patient safety.
April 16, 2018
George BC, Dunnington GL, DaRosa DA. Trainee autonomy and patient safety. Ann Surg.
2018;267(5):820-822. doi:10.1097/SLA.0000000000002599.
https://psnet.ahrq.gov/issue/trainee-autonomy-and-patient-safety
Reduced resident work hours and insufficient senior surgeon…
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psnet.ahrq.gov/node/61003/psn-pdf
October 07, 2020 - Making Complaints Count: Supporting Complaints
Handling in the NHS and UK Government Departments.
October 7, 2020
Manchester, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN
9781528620666.
https://psnet.ahrq.gov/issue/making-complaints-count-supporting-complaints-handling-nhs-and-uk-
gover…
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psnet.ahrq.gov/node/37469/psn-pdf
January 16, 2008 - Towards the reduction of medication errors in
orthopedics and spinal surgery: outcomes using a
pharmacist-led approach.
January 16, 2008
Weiner BK, Venarske J, Yu M, et al. Towards the reduction of medication errors in orthopedics and spinal
surgery: outcomes using a pharmacist-led approach. Spine (Phila Pa 1976).…
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psnet.ahrq.gov/node/35176/psn-pdf
June 23, 2009 - Mapping changes in surgical mortality over 9 years by
peer review audit.
June 23, 2009
Thompson A, Ashraf Z, Burton H, et al. Mapping changes in surgical mortality over 9 years by peer review
audit. Br J Surg. 2005;92(11):1449-52.
https://psnet.ahrq.gov/issue/mapping-changes-surgical-mortality-over-9-years-peer-re…
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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/46322/psn-pdf
August 02, 2017 - Sophisticated digital aids could help determine what ails
you.
August 2, 2017
Maron DF. Scientific American. July 21, 2017.
https://psnet.ahrq.gov/issue/sophisticated-digital-aids-could-help-determine-what-ails-you
Clinical decision support systems are a key strategy to improve diagnostic accuracy. This magazine a…
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psnet.ahrq.gov/node/44843/psn-pdf
September 06, 2016 - Addressing the Global Shortages of Medicines, and the
Safety and Accessibility of Children's Medication.
September 6, 2016
Geneva, Switzerland: World Health Organization; 2015.
https://psnet.ahrq.gov/issue/addressing-global-shortages-medicines-and-safety-and-accessibility-childrens-
medication
Drug shortages have…
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psnet.ahrq.gov/node/47855/psn-pdf
June 19, 2019 - Medication Overload: America's Other Drug Problem.
June 19, 2019
Brownlee S; Garber J. Brookline, MA: Lown Institute; 2019.
https://psnet.ahrq.gov/issue/medication-overload-americas-other-drug-problem
Overprescribing is a common problem that contributes to patient harm. This report examines financial,
clinical, an…
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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/41425/psn-pdf
June 19, 2012 - Mortality and morbidity meetings: an untapped resource
for improving the governance of patient safety?
June 19, 2012
Higginson J, Walters R, Fulop NJ. Mortality and morbidity meetings: an untapped resource for improving
the governance of patient safety? BMJ Qual Saf. 2012;21(7):576-585. doi:10.1136/bmjqs-2011-00060…
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psnet.ahrq.gov/node/47381/psn-pdf
April 03, 2019 - The role of the patient in patient safety: what can we learn
from healthcare's history?
April 3, 2019
Leistikow I, Huisman F. The role of the patient in patient safety: What can we learn from healthcare's
history? J Patient Saf Risk Manag. 2018;23(4):139-141. doi:10.1177/2516043518791051.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/44838/psn-pdf
February 10, 2016 - ADVERSE drug events: incidence and risk reduction
across the care continuum.
February 10, 2016
Wanderer JP, Rathmell JP. ADVERSE Drug Events: Incidence & risk reduction across the care continuum.
Anesthesiology. 2016;124(1):A23. doi:10.1097/01.anes.0000473722.20007.03.
https://psnet.ahrq.gov/issue/adverse-drug-eve…
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psnet.ahrq.gov/node/43786/psn-pdf
December 17, 2014 - Aviation tools to improve patient safety.
December 17, 2014
Ross J. Aviation tools to improve patient safety. J Perianesth Nurs. 2014;29(6):508-10.
doi:10.1016/j.jopan.2014.09.004.
https://psnet.ahrq.gov/issue/aviation-tools-improve-patient-safety
The aviation industry offers insights and tools applicable to error…
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psnet.ahrq.gov/node/50425/psn-pdf
September 04, 2019 - Why doctors still offer treatments that may not help.
September 4, 2019
Frakt A. New York Times. August 26, 2019.
https://psnet.ahrq.gov/issue/why-doctors-still-offer-treatments-may-not-help
The slow adoption of improvement innovations is a persistent challenge to high-quality and safe patient
care. This newspaper…
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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…