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psnet.ahrq.gov/node/38839/psn-pdf
August 05, 2009 - Polypharmacy in hospitalized older adult cancer patients:
experience from a prospective, observational study of an
oncology-acute care for elders unit.
August 5, 2009
Flood KL, Carroll MB, Le C, et al. Polypharmacy in hospitalized older adult cancer patients: experience
from a prospective, observational study of…
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psnet.ahrq.gov/node/40541/psn-pdf
July 22, 2011 - Effect of a pharmacist-led multicomponent intervention
focusing on the medication monitoring phase to prevent
potential adverse drug events in nursing homes.
July 22, 2011
Lapane KL, Hughes C, Daiello LA, et al. Effect of a pharmacist-led multicomponent intervention focusing on
the medication monitoring phase to p…
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psnet.ahrq.gov/node/46758/psn-pdf
April 12, 2019 - Association of hospitalist years of experience with
mortality in the hospitalized Medicare population.
April 12, 2019
Goodwin JS, Salameh H, Zhou J, et al. Association of Hospitalist Years of Experience With Mortality in the
Hospitalized Medicare Population. JAMA Intern Med. 2017;178(2). doi:10.1001/jamainternmed.2…
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psnet.ahrq.gov/node/865978/psn-pdf
May 29, 2024 - Ensuring safe and equitable discharge: a quality
improvement initiative for individuals with hypertensive
disorders of pregnancy.
May 29, 2024
Zacherl KM, Sterrett EC, Hughes BL, et al. Ensuring safe and equitable discharge: a quality improvement
initiative for individuals with hypertensive disorders of pregnancy.…
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psnet.ahrq.gov/node/42489/psn-pdf
May 19, 2014 - Improving medication administration safety in solid organ
transplant patients through barcode-assisted medication
administration.
May 19, 2014
Bonkowski J, Weber RJ, Melucci J, et al. Improving medication administration safety in solid organ
transplant patients through barcode-assisted medication administration. A…
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psnet.ahrq.gov/node/34890/psn-pdf
February 17, 2011 - Electronic alerts to prevent venous thromboembolism
among hospitalized patients.
February 17, 2011
Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized
patients. N Engl J Med. 2005;352(10):969-77.
https://psnet.ahrq.gov/issue/electronic-alerts-prevent-venous-thro…
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psnet.ahrq.gov/node/45625/psn-pdf
November 01, 2017 - Building comprehensive strategies for obstetric safety:
simulation drills and communication.
November 1, 2017
Austin N, Goldhaber-Fiebert SN, Daniels K, et al. Building Comprehensive Strategies for Obstetric Safety:
Simulation Drills and Communication. Anesth Analg. 2016;123(5):1181-1190.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/73612/psn-pdf
August 18, 2021 - Evaluating the impact of radio frequency identification
retained surgical instruments tracking on patient safety:
literature review.
August 18, 2021
Schnock KO, Biggs B, Fladger A, et al. Evaluating the impact of radio frequency identification retained
surgical instruments tracking on patient safety: literature re…
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psnet.ahrq.gov/node/34868/psn-pdf
February 03, 2011 - Role of computerized physician order entry systems in
facilitating medication errors.
February 3, 2011
Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating
medication errors. JAMA. 2005;293(10):1197-203.
https://psnet.ahrq.gov/issue/role-computerized-physician-ord…
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psnet.ahrq.gov/node/42673/psn-pdf
October 30, 2013 - Clinical evaluation of the ADE scorecards as a decision
support tool for adverse drug event analysis and
medication safety management.
October 30, 2013
Hackl WO, Ammenwerth E, Marcilly R, et al. Clinical evaluation of the ADE scorecards as a decision
support tool for adverse drug event analysis and medication safe…
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psnet.ahrq.gov/node/47503/psn-pdf
October 24, 2018 - I-PASS checklist: a powerful tool for patient handoffs.
October 24, 2018
Peeples L. Pharmacy Practice News. October 10, 2018.
https://psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs
Structured handoffs can reduce communication problems that contribute to medical error. This magazine
article re…
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psnet.ahrq.gov/node/45331/psn-pdf
August 03, 2016 - Health information technologies: from hazardous to the
dark side.
August 3, 2016
Saunders C, Rutkowski AF, Pluyter J, et al. Health information technologies: From hazardous to the dark
side. J Assoc Inf Sci Technol. 2016;67(7). doi:10.1002/asi.23671.
https://psnet.ahrq.gov/issue/health-information-technologies-haz…
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psnet.ahrq.gov/node/35130/psn-pdf
March 11, 2011 - A trial of automated decision support alerts for
contraindicated medications using computerized
physician order entry.
March 11, 2011
Galanter W, Didomenico RJ, Polikaitis A. A trial of automated decision support alerts for contraindicated
medications using computerized physician order entry. J Am Med Inform Assoc…
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psnet.ahrq.gov/node/860733/psn-pdf
January 17, 2024 - Staff warned about the lack of psychiatric care at a VA
clinic. They couldn’t prevent tragedy.
January 17, 2024
McGrory K, Bedi N. ProPublica, January 6, 2024.
https://psnet.ahrq.gov/issue/staff-warned-about-lack-psychiatric-care-va-clinic-they-couldnt-prevent-tragedy
Stories of mental health system failure provid…
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psnet.ahrq.gov/node/61033/psn-pdf
October 14, 2020 - L.A.’s poorest patients endure long delays to see medical
specialists. Some die waiting.
October 14, 2020
Dolan J, Mejia B. Los Angeles Times. September 30, 2020.
https://psnet.ahrq.gov/issue/las-poorest-patients-endure-long-delays-see-medical-specialists-some-die-
waiting
Socioeconomic conditions influence acces…
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psnet.ahrq.gov/node/39860/psn-pdf
September 01, 2017 - Interventions to improve hand hygiene compliance in
patient care.
September 1, 2017
Gould DJ, Moralejo D, Drey N, et al. Interventions to improve hand hygiene compliance in patient care.
Cochrane Database Syst Rev. 2017;9(9):CD005186. doi:10.1002/14651858.cd005186.pub4.
https://psnet.ahrq.gov/issue/interventions-i…
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psnet.ahrq.gov/node/45444/psn-pdf
December 04, 2016 - Alarm fatigue: use of an evidence-based alarm
management strategy.
December 4, 2016
Turmell JW, Coke L, Catinella R, et al. Alarm Fatigue. J Nurs Care Qual. 2016;32(1):47-54.
doi:10.1097/ncq.0000000000000223.
https://psnet.ahrq.gov/issue/alarm-fatigue-use-evidence-based-alarm-management-strategy
Reducing nuisance…
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psnet.ahrq.gov/node/46311/psn-pdf
August 23, 2017 - Swimming against the tide: primary care physicians'
views on deprescribing in everyday practice.
August 23, 2017
Wallis KA, Andrews A, Henderson M. Swimming Against the Tide: Primary Care Physicians’ Views on
Deprescribing in Everyday Practice. Ann Fam Med. 2017;15(4):341-346. doi:10.1370/afm.2094.
https://psnet.a…
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psnet.ahrq.gov/node/60286/psn-pdf
April 29, 2020 - With Covid-19 delaying routine care, chronic disease
startups brace for a slew of complications.
April 29, 2020
Brodwin E. STAT. April 14, 2020.
https://psnet.ahrq.gov/issue/covid-19-delaying-routine-care-chronic-disease-startups-brace-slew-
complications
Patients with cancer and other chronic disorder treatment …
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psnet.ahrq.gov/node/47800/psn-pdf
June 26, 2019 - Error and Uncertainty in Diagnostic Radiology.
June 26, 2019
Bruno MA. New York, NY: Oxford University Press; 2019. ISBN: 9780190665395.
https://psnet.ahrq.gov/issue/error-and-uncertainty-diagnostic-radiology
Despite enhancements in medical imaging technology, diagnostic radiologists are still susceptible to
uncer…