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psnet.ahrq.gov/node/34643/psn-pdf
December 23, 2008 - The health care cost of drug-related morbidity and
mortality in nursing facilities.
December 23, 2008
Bootman JL, Harrison DL, Cox E. The health care cost of drug-related morbidity and mortality in nursing
facilities. Arch Intern Med. 1997;157(18):2089-96.
https://psnet.ahrq.gov/issue/health-care-cost-drug-related…
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psnet.ahrq.gov/node/838137/psn-pdf
September 21, 2022 - How insight contributes to diagnostic excellence.
September 21, 2022
Shimizu T, Graber ML. How insight contributes to diagnostic excellence. Diagnosis (Berl). 2022;9(3):311-
315. doi:10.1515/dx-2022-0007.
https://psnet.ahrq.gov/issue/how-insight-contributes-diagnostic-excellence
Improving diagnostic reasoning skil…
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psnet.ahrq.gov/node/43565/psn-pdf
March 22, 2016 - The role of failure mode and effects analysis in health
care.
March 22, 2016
Fibuch E, Ahmed A. The role of failure mode and effects analysis in health care. Physician Exec.
2014;40(4):28-32.
https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care
Failure mode and effects analysis (FMEA) h…
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psnet.ahrq.gov/node/837154/psn-pdf
May 18, 2022 - Survey shows room for improvement with three new best
practices for hospitals.
May 18, 2022
ISMP Medication Safety Alert! Acute care edition. May 5, 2022;27(9):1-5.
https://psnet.ahrq.gov/issue/survey-shows-room-improvement-three-new-best-practices-hospitals
Practice changes take time to be fully incorporate…
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psnet.ahrq.gov/node/854382/psn-pdf
October 11, 2023 - Battling alarm fatigue in the pediatric intensive care unit.
October 11, 2023
Herrera H, Wood D. Battling alarm fatigue in the pediatric intensive care unit. Crit Care Nurs Clin North Am.
2023;35(3):347-355. doi:10.1016/j.cnc.2023.05.003.
https://psnet.ahrq.gov/issue/battling-alarm-fatigue-pediatric-intensive-care-…
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psnet.ahrq.gov/node/38099/psn-pdf
October 01, 2008 - Decreased bile duct injury rate during laparoscopic
cholecystectomy in the era of the 80-hour resident
workweek.
October 1, 2008
Yaghoubian A, Saltmarsh G, Rosing DK, et al. Decreased bile duct injury rate during laparoscopic
cholecystectomy in the era of the 80-hour resident workweek. Arch Surg. 2008;143(9):847-5…
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psnet.ahrq.gov/node/34978/psn-pdf
June 30, 2011 - Personal digital assistant-based drug information
sources: potential to improve medication safety.
June 30, 2011
Galt K, Rule AM, Houghton B, et al. Personal digital assistant-based drug information sources: potential to
improve medication safety. J Med Libr Assoc. 2005;93(2):229-36.
https://psnet.ahrq.gov/issue/p…
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psnet.ahrq.gov/node/45373/psn-pdf
November 18, 2016 - Prevalence, risk factors, and outcomes of idle
intravenous catheters: an integrative review.
November 18, 2016
Becerra MB, Shirley D, Safdar N. Prevalence, risk factors, and outcomes of idle intravenous catheters: An
integrative review. Am J Infect Control. 2016;44(10):e167-e172. doi:10.1016/j.ajic.2016.03.073.
ht…
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psnet.ahrq.gov/node/44386/psn-pdf
August 12, 2015 - Using simulation to improve systems.
August 12, 2015
Lundberg PW, Korndorffer JR. Using Simulation to Improve Systems. Surg Clin North Am. 2015;95(4):885-
92. doi:10.1016/j.suc.2015.04.007.
https://psnet.ahrq.gov/issue/using-simulation-improve-systems
Safety approaches from aviation that can be applied to health c…
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psnet.ahrq.gov/node/74070/psn-pdf
November 10, 2021 - ERs are swamped with seriously ill patients, although
many don’t have Covid.
November 10, 2021
Wells K. Health Shots. National Public Radio. October 29, 2021.
https://psnet.ahrq.gov/issue/ers-are-swamped-seriously-ill-patients-although-many-dont-have-covid
Emergency department (ED) crowding stemming from treatment…
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psnet.ahrq.gov/node/837760/psn-pdf
January 01, 2024 - Criminal liability for nursing and medical harm.
August 3, 2022
Maher V, Cwiek M. Criminal liability for nursing and medical harm. Hosp Top. 2024;102(2):117-124.
doi:10.1080/00185868.2022.2101571.
https://psnet.ahrq.gov/issue/criminal-liability-nursing-and-medical-harm
Fear of criminal liability may inhibit clinic…
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psnet.ahrq.gov/node/73911/psn-pdf
October 06, 2021 - Misdiagnosis of acute myocardial infarction: a systematic
review of the literature.
October 6, 2021
Kwok CS, Bennett S, Azam Z, et al. Misdiagnosis of acute myocardial infarction: a systematic review of the
literature. Crit Pathw Cardiol. 2021;20(3):155-162. doi:10.1097/hpc.0000000000000256.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/44404/psn-pdf
August 26, 2015 - Nurse interrupted: development of a realistic medication
administration simulation for undergraduate nurses.
August 26, 2015
Hayes C, Power T, Davidson PM, et al. Nurse interrupted: Development of a realistic medication
administration simulation for undergraduate nurses. Nurse Educ Today. 2015;35(9):981-6.
doi:10.…
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psnet.ahrq.gov/node/38777/psn-pdf
March 04, 2011 - Perceptions of standards-based electronic prescribing
systems as implemented in outpatient primary care: a
physician survey.
March 4, 2011
Wang J, Patel MH, Schueth AJ, et al. Perceptions of standards-based electronic prescribing systems as
implemented in outpatient primary care: a physician survey. J Am Med Infor…
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psnet.ahrq.gov/node/44123/psn-pdf
July 11, 2018 - The 2014 John M. Eisenberg Patient Safety and Quality
Awards.
July 11, 2018
Jt Comm J Qual Patient Saf. 2015;41(5):195-211.
https://psnet.ahrq.gov/issue/2014-john-m-eisenberg-patient-safety-and-quality-awards
Articles in this special issue highlight the achievements of the 2014 John M. Eisenberg Patient Safety and…
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psnet.ahrq.gov/node/844800/psn-pdf
September 25, 2019 - Patient Options for Safe and Effective Disposal of Unused
Opioids.
September 25, 2019
Washington, DC: United States Government Accountability Office; September 2019. Publication GAO-19-
650.
https://psnet.ahrq.gov/issue/patient-options-safe-and-effective-disposal-unused-opioids
One strategy to reduce the potentia…
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psnet.ahrq.gov/node/50925/psn-pdf
February 19, 2020 - Report of the Independent Inquiry into the Issues Raised
by Paterson.
February 19, 2020
James G. House Commons Report 31. Department of Health and Social Care. London,
England: Crown Copyright; 2020. ISBN 9781528617284.
https://psnet.ahrq.gov/issue/report-independent-inquiry-issues-raised-paterson
Shari…
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psnet.ahrq.gov/node/35048/psn-pdf
June 22, 2009 - Reduction in warfarin adverse events requiring patient
hospitalization after implementation of a pharmacist-
managed anticoagulation service.
June 22, 2009
Locke C, Ravnan SL, Patel R, et al. Reduction in warfarin adverse events requiring patient hospitalization
after implementation of a pharmacist-managed anticoa…
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psnet.ahrq.gov/node/45094/psn-pdf
May 04, 2016 - Actions Needed to Improve Newly Enrolled Veterans'
Access to Primary Care.
May 4, 2016
Washington, DC: United States Government Accountability Office; March 18, 2016. Publication GAO-16-
328.
https://psnet.ahrq.gov/issue/actions-needed-improve-newly-enrolled-veterans-access-primary-care
This analysis found that s…
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psnet.ahrq.gov/node/45764/psn-pdf
April 11, 2018 - Pediatric anesthesiology fellows' perception of quality of
attending supervision and medical errors.
April 11, 2018
Benzon HA, Hajduk J, De Oliveira GS, et al. Pediatric Anesthesiology Fellows' Perception of Quality of
Attending Supervision and Medical Errors. Anesth Analg. 2018;126(2):639-643.
doi:10.1213/ANE.000…