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psnet.ahrq.gov/node/43945/psn-pdf
September 09, 2015 - Hospital and procedure incidence of pediatric retained
surgical items.
September 9, 2015
Wang B, Tashiro J, Perez EA, et al. Hospital and procedure incidence of pediatric retained surgical items. J
Surg Res. 2015;198(2):400-5. doi:10.1016/j.jss.2015.03.054.
https://psnet.ahrq.gov/issue/hospital-and-procedure-incid…
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psnet.ahrq.gov/node/34594/psn-pdf
January 04, 2017 - John M. Eisenberg Patient Safety Awards. The Leapfrog
Group for Patient Safety: rewarding higher standards.
January 4, 2017
Eikel C, Delbanco S. John M. Eisenberg Patient Safety Awards. The Leapfrog Group for Patient Safety:
rewarding higher standards. Jt Comm J Qual Saf. 2003;29(12):634-9.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/45826/psn-pdf
January 18, 2017 - Ensuring staff safety when treating potentially violent
patients.
January 18, 2017
Roca RP, Charen B, Boronow J. Ensuring Staff Safety When Treating Potentially Violent Patients. JAMA.
2016;316(24):2669-2670. doi:10.1001/jama.2016.18260.
https://psnet.ahrq.gov/issue/ensuring-staff-safety-when-treating-potentially-…
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psnet.ahrq.gov/node/37709/psn-pdf
April 23, 2008 - Inappropriate medication use in the elderly: results from a
quality improvement project in 99 primary care practices.
April 23, 2008
Wessell AM, Nietert PJ, Jenkins RG, et al. Inappropriate medication use in the elderly: Results from a
quality improvement project in 99 primary care practices. Am J Geriatr Pharmacot…
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psnet.ahrq.gov/node/46554/psn-pdf
October 25, 2017 - Severe hyperglycemia in patients incorrectly using insulin
pens at home.
October 25, 2017
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American
Society of Health-System Pharmacists. October 12, 2017.
https://psnet.ahrq.gov/issue/severe-hyperglycemia-patients-incorrect…
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psnet.ahrq.gov/node/44009/psn-pdf
July 18, 2016 - Automated communication tools and computer-based
medication reconciliation to decrease hospital discharge
medication errors.
July 18, 2016
Smith KJ, Handler S, Kapoor WN, et al. Automated Communication Tools and Computer-Based Medication
Reconciliation to Decrease Hospital Discharge Medication Errors. Am J Med Qua…
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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/851204/psn-pdf
July 05, 2023 - Drugmakers are abandoning cheap generics, and now US
cancer patients can’t get meds.
July 5, 2023
Allen A. KFF Health News. June 21, 2023.
https://psnet.ahrq.gov/issue/drugmakers-are-abandoning-cheap-generics-and-now-us-cancer-patients-
cant-get-meds
A variety of supply-chain, quality control, and economic factor…
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psnet.ahrq.gov/node/45082/psn-pdf
April 27, 2016 - Surgeons must tell patients of double-booked surgeries,
new guidelines say.
April 27, 2016
Abelson J, Staltzman J. Boston Globe. April 13, 2016.
https://psnet.ahrq.gov/issue/surgeons-must-tell-patients-double-booked-surgeries-new-guidelines-say
Although scheduling overlapping surgeries may improve operating room e…
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psnet.ahrq.gov/node/840163/psn-pdf
November 16, 2022 - Deep Dive: Racial and Ethnic Disparities in Health and
Healthcare.
November 16, 2022
Plymouth Meeting, PA: ECRI and the Institute for Safe Medication Practices; 2022.
https://psnet.ahrq.gov/issue/deep-dive-racial-and-ethnic-disparities-health-and-healthcare
Racist behavior directed at either patients or clinicians…
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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/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/44425/psn-pdf
February 24, 2016 - Dangerous doses.
February 24, 2016
Roe S, King K. Chicago Tribune. February 10–13, 2016.
https://psnet.ahrq.gov/issue/dangerous-doses
Drug interactions can be hazardous to patients, particularly when combined with risk factors such as age
and use of medications for chronic conditions. This series of news reports d…
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psnet.ahrq.gov/node/72499/psn-pdf
November 25, 2020 - Transformational improvement in quality care and health
systems: the next decade.
November 25, 2020
Braithwaite J, Vincent CA, Garcia-Elorrio E, et al. Transformational improvement in quality care and health
systems: the next decade. BMC Med. 2020;18(1):340. doi:10.1186/s12916-020-01739-y.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/43307/psn-pdf
September 26, 2016 - Mitigating errors caused by interruptions during
medication verification and administration: interventions
in a simulated ambulatory chemotherapy setting.
September 26, 2016
Prakash V, Koczmara C, Savage P, et al. Mitigating errors caused by interruptions during medication
verification and administration: interven…
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psnet.ahrq.gov/node/74011/psn-pdf
October 27, 2021 - Dashboards for visual display of patient safety data: a
systematic review.
October 27, 2021
Murphy DR, Savoy A, Satterly T, et al. Dashboards for visual display of patient safety data: a systematic
review. BMJ Health Care Inform. 2021;28(1):e100437. doi:10.1136/bmjhci-2021-100437.
https://psnet.ahrq.gov/issue/dash…
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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/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/45188/psn-pdf
June 01, 2016 - Reporting and second-order problem solving can turn
short-term fixes into long-term remedies.
June 1, 2016
ISMP Medication Safety Alert! Acute Care Edition. May 19, 2016;21:1-4.
https://psnet.ahrq.gov/issue/reporting-and-second-order-problem-solving-can-turn-short-term-fixes-long-
term-remedies
Workarounds are pr…
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psnet.ahrq.gov/node/43078/psn-pdf
June 03, 2014 - The value of autopsies in the era of high-tech medicine:
discrepant findings persist.
June 3, 2014
Kuijpers CCHJ, Fronczek J, van de Goot FRW, et al. The value of autopsies in the era of high-tech
medicine: discrepant findings persist. J Clin Pathol. 2014;67(6):512-9. doi:10.1136/jclinpath-2013-202122.
https://psn…