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psnet.ahrq.gov/node/39263/psn-pdf
February 03, 2010 - Is there a benefit to multidisciplinary rounds in an open
trauma intensive care unit regarding ventilator-associated
pneumonia?
February 3, 2010
Johnson V, Mangram A, Mitchell C, et al. Is there a benefit to multidisciplinary rounds in an open trauma
intensive care unit regarding ventilator-associated pneumonia? A…
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psnet.ahrq.gov/node/41911/psn-pdf
December 12, 2012 - Effects of an intervention to increase bed alarm use to
prevent falls in hospitalized patients: a cluster
randomized trial.
December 12, 2012
Shorr RI, Chandler M, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in
hospitalized patients: a cluster randomized trial. Ann Intern …
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psnet.ahrq.gov/node/43819/psn-pdf
July 16, 2015 - Intercepting wrong-patient orders in a computerized
provider order entry system.
July 16, 2015
Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider
order entry system. Ann Emerg Med. 2015;65(6):679-686.e1. doi:10.1016/j.annemergmed.2014.11.017.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/74703/psn-pdf
January 26, 2022 - Research to improve diagnosis: time to study the real
world.
January 26, 2022
Ranji SR, Thomas EJ. Research to improve diagnosis: time to study the real world. BMJ Qual Saf.
2022;31(4):255-258. doi:10.1136/bmjqs-2021-014071.
https://psnet.ahrq.gov/issue/research-improve-diagnosis-time-study-real-world
Diagnostic …
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psnet.ahrq.gov/node/46090/psn-pdf
December 22, 2018 - More than a tick box: medical checklist development,
design, and use.
December 22, 2018
Burian BK, Clebone A, Dismukes K, et al. More Than a Tick Box: Medical Checklist Development, Design,
and Use. Anesth Analg. 2018;126(1):223-232. doi:10.1213/ANE.0000000000002286.
https://psnet.ahrq.gov/issue/more-tick-box-medi…
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psnet.ahrq.gov/node/40985/psn-pdf
December 07, 2011 - Implementing the World Health Organization surgical
safety checklist: a model for future perioperative
initiatives.
December 7, 2011
Styer KA, Ashley SW, Schmidt I, et al. Implementing the World Health Organization surgical safety
checklist: a model for future perioperative initiatives. AORN J. 2011;94(6):590-8.
…
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psnet.ahrq.gov/node/72674/psn-pdf
January 27, 2021 - The effect of blue-enriched lighting on medical error rate
in a university hospital ICU.
January 27, 2021
Chen Y, Broman AT, Priest G, et al. The Effect of Blue-Enriched Lighting on Medical Error Rate in a
University Hospital ICU. Jt Comm J Qual Saf. 2021;47(3):165-175. doi:10.1016/j.jcjq.2020.11.007.
https://psne…
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psnet.ahrq.gov/node/60263/psn-pdf
April 22, 2020 - Rationing protective gear means checking on coronavirus
patients less often. This can be deadly.
April 22, 2020
Kaplan J, Presser L, Miller M. ProPublica. April 10, 2020.
https://psnet.ahrq.gov/issue/rationing-protective-gear-means-checking-coronavirus-patients-less-often-can-
be-deadly
Increased complexity and p…
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psnet.ahrq.gov/node/39511/psn-pdf
November 02, 2010 - Prospective pilot intervention study to prevent medication
errors in drugs administered to children by mouth or
gastric tube: a programme for nurses, physicians and
parents.
November 2, 2010
Bertsche T, Bertsche A, Krieg E-M, et al. Prospective pilot intervention study to prevent medication errors
in drugs admini…
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psnet.ahrq.gov/node/41285/psn-pdf
June 01, 2012 - Effect of medication reconciliation at hospital admission
on medication discrepancies during hospitalization and at
discharge for geriatric patients.
June 1, 2012
Cornu P, Steurbaut S, Leysen T, et al. Effect of medication reconciliation at hospital admission on
medication discrepancies during hospitalization and …
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psnet.ahrq.gov/node/47464/psn-pdf
October 17, 2018 - How to prevent the top 4 medication errors.
October 17, 2018
Sederstrom J. Drug Topics. September 17, 2018.
https://psnet.ahrq.gov/issue/how-prevent-top-4-medication-errors
Medication errors continue to be a worldwide patient safety challenge that requires both systems and
individual practice strategies for improv…
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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/47632/psn-pdf
April 10, 2019 - Perception of the usability and implementation of a
metacognitive mnemonic to check cognitive errors in
clinical setting.
April 10, 2019
Chew KS, van Merrienboer JJG, Durning SJ. Perception of the usability and implementation of a
metacognitive mnemonic to check cognitive errors in clinical setting. BMC Med Educ. …
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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/37262/psn-pdf
December 19, 2011 - Academic detailing to improve laboratory testing among
outpatient medication users.
December 19, 2011
Lafata JE, Gunter MJ, Hsu J, et al. Academic detailing to improve laboratory testing among outpatient
medication users. Med Care. 2007;45(10):966-72.
https://psnet.ahrq.gov/issue/academic-detailing-improve-laborat…
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psnet.ahrq.gov/node/44224/psn-pdf
June 10, 2015 - To be sued less, doctors should consider talking to
patients more.
June 10, 2015
Carroll AE.
https://psnet.ahrq.gov/issue/be-sued-less-doctors-should-consider-talking-patients-more
Reporting on trends associated with medical malpractice, how the same physicians tend to get sued, and
reasons patients file claims, …
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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/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/47597/psn-pdf
August 07, 2019 - Intentional rounding—an integrative literature review.
August 7, 2019
Ryan L, Jackson D, Woods C, et al. Intentional rounding - An integrative literature review. J Adv Nurs.
2019;75(6):1151-1161. doi:10.1111/jan.13897.
https://psnet.ahrq.gov/issue/intentional-rounding-integrative-literature-review
This review exam…
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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…