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psnet.ahrq.gov/node/43860/psn-pdf
March 25, 2015 - Pharmacy dispensing errors: claims study emphasizes
need for systematic vigilance.
March 25, 2015
Webb J. Drug Topics. March 10, 2015.
https://psnet.ahrq.gov/issue/pharmacy-dispensing-errors-claims-study-emphasizes-need-systematic-
vigilance
Pharmacies can serve as gatekeepers to ensure patients receive the corre…
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October 26, 2022 - Effect of pharmacist email alerts on concurrent
prescribing of opioids and benzodiazepines by
prescribers and primary care managers: a randomized
clinical trial.
October 26, 2022
Sacarny A, Safran E, Steffel M, et al. Effect of pharmacist email alerts on concurrent prescribing of opioids
and benzodiazepines by pr…
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psnet.ahrq.gov/node/50932/psn-pdf
February 26, 2020 - Clinician-directed performance improvement: moving
beyond externally mandated metrics.
February 26, 2020
Goitein L. Clinician-directed performance improvement: moving beyond externally mandated metrics.
Health Aff (Millwood). 2020;39(2). doi:10.1377/hlthaff.2019.00505.
https://psnet.ahrq.gov/issue/clinician-direct…
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psnet.ahrq.gov/node/50416/psn-pdf
September 04, 2019 - Perceptual and interpretive error in diagnostic
radiology—causes and potential solutions.
September 4, 2019
Degnan AJ, Ghobadi EH, Hardy P, et al. Perceptual and Interpretive Error in Diagnostic Radiology-Causes
and Potential Solutions. Acad Radiol. 2019;26(6):833-845. doi:10.1016/j.acra.2018.11.006.
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November 08, 2023 - Identifying barriers and enablers for a robust independent
second check of medication in adult intensive care.
November 8, 2023
Milic V, Cameron L, Jones C. Identifying barriers and enablers for a robust independent second check of
medication in adult intensive care. Br J Nurs. 2023;32(17):840-848. doi:10.12968/bjo…
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psnet.ahrq.gov/node/44801/psn-pdf
June 22, 2016 - Safety for all: integrated design for inpatient units.
June 22, 2016
Hunt JM, Sine DM. Patient Saf Qual Healthc. May/June 2016;13:20-28.
https://psnet.ahrq.gov/issue/safety-all-integrated-design-inpatient-units
Design is emerging as an important tactic to augment safe care delivery. Hospitals that provide care for
…
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psnet.ahrq.gov/node/37430/psn-pdf
February 01, 2011 - Nonpayment for harms resulting from medical care:
catheter-associated urinary tract infections.
February 1, 2011
Wald HL, Kramer AM. Nonpayment for harms resulting from medical care: catheter-associated urinary tract
infections. JAMA. 2007;298(23):2782-4. doi:10.1001/jama.298.23.2782.
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psnet.ahrq.gov/node/45845/psn-pdf
December 19, 2017 - You can't blame the wreck on the train.
December 19, 2017
Potts JR. You can't blame the wreck on the train. Am J Surg. 2017;214(5):974-978.
doi:10.1016/j.amjsurg.2016.11.046.
https://psnet.ahrq.gov/issue/you-cant-blame-wreck-train
Insufficient supervision can limit resident education, which may increase risks to p…
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psnet.ahrq.gov/node/45823/psn-pdf
May 09, 2017 - The effect of prescriber education on medication-related
patient harm in the hospital: a systematic review.
May 9, 2017
Bos JM, van den Bemt PMLA, de Smet PAGM, et al. The effect of prescriber education on medication-
related patient harm in the hospital: a systematic review. Br J Clin Pharmacol. 2017;83(5):953-961…
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psnet.ahrq.gov/node/46070/psn-pdf
May 10, 2017 - Frequency, expected effects, obstacles, and facilitators of
disclosure of patient safety incidents: a systematic
review.
May 10, 2017
Ock M, Lim SY, Jo M-W, et al. Frequency, Expected Effects, Obstacles, and Facilitators of Disclosure of
Patient Safety Incidents: A Systematic Review. J Prev Med Public Health. 2017…
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psnet.ahrq.gov/node/46270/psn-pdf
April 16, 2018 - Impact of a restraint management bundle on restraint use
in an intensive care unit.
April 16, 2018
Hall DK, Zimbro KS, Maduro RS, et al. Impact of a Restraint Management Bundle on Restraint Use in an
Intensive Care Unit. J Nurs Care Qual. 2018;33(2):143-148. doi:10.1097/NCQ.0000000000000273.
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psnet.ahrq.gov/node/47713/psn-pdf
June 14, 2019 - Medication appropriateness in vulnerable older adults:
healthy skepticism of appropriate polypharmacy.
June 14, 2019
Fried TR, Mecca MC. Medication Appropriateness in Vulnerable Older Adults: Healthy Skepticism of
Appropriate Polypharmacy. J Am Geriatr Soc. 2019;67(6):1123-1127. doi:10.1111/jgs.15798.
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March 25, 2017 - Data-driven implementation of alarm reduction
interventions in a cardiovascular surgical ICU.
March 25, 2017
Allan SH, Doyle PA, Sapirstein A, et al. Data-Driven Implementation of Alarm Reduction Interventions in a
Cardiovascular Surgical ICU. Jt Comm J Qual Patient Saf. 2017;43(2):62-70.
doi:10.1016/j.jcjq.2016.1…
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psnet.ahrq.gov/node/44657/psn-pdf
November 11, 2015 - Understanding and confronting our mistakes: the
epidemiology of error in radiology and strategies for error
reduction.
November 11, 2015
Bruno MA, Walker EA, Abujudeh H. Understanding and confronting our mistakes: the epidemiology of error
in radiology and strategies for error reduction. Radiographics. 2015;35(6):…
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July 10, 2024 - Analysis of critical incident reports using natural
language processing.
July 10, 2024
Denecke K, Paula H. Analysis of critical incident reports using natural language processing. Stud Health
Technol Inform. 2024;313:1-6. doi:10.3233/shti240002.
https://psnet.ahrq.gov/issue/analysis-critical-incident-reports-using…
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psnet.ahrq.gov/node/865661/psn-pdf
April 24, 2024 - Pay-for-performance and patient safety in acute care: a
systematic review.
April 24, 2024
Slawomirski L, Hensher M, Campbell JL, et al. Pay-for-performance and patient safety in acute care: a
systematic review. Health Policy. 2024;143:105051. doi:10.1016/j.healthpol.2024.105051.
https://psnet.ahrq.gov/issue/pay-pe…
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psnet.ahrq.gov/node/50569/psn-pdf
October 23, 2019 - Design and implementation of a tool for pharmacists to
register potential errors in prescribed medication.
October 23, 2019
Frid S, Zapico V, Mansilla A, et al. Design and Implementation of a Tool for Pharmacists to Register
Potential Errors in Prescribed Medication. Stud Health Technol Inform. 2019;264:581-585.
d…
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psnet.ahrq.gov/node/46456/psn-pdf
February 28, 2018 - Drug calculation ability of qualified paramedics: a pilot
study.
February 28, 2018
Boyle MJ, Eastwood K. Drug calculation ability of qualified paramedics: A pilot study. World J Emerg Med.
2018;9(1):41-45. doi:10.5847/wjem.j.1920-8642.2018.01.006.
https://psnet.ahrq.gov/issue/drug-calculation-ability-qualified-par…
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psnet.ahrq.gov/node/46811/psn-pdf
May 17, 2018 - A surgical procedure grid for safety and operating room
communication in multisite surgery.
May 17, 2018
Insalaco LF, Spiegel JH. A Surgical Procedure Grid for Safety and Operating Room Communication in
Multisite Surgery. JAMA Facial Plast Surg. 2018;20(3):185-186. doi:10.1001/jamafacial.2017.2049.
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April 22, 2020 - Discrepancies in written versus calculated durations in
opioid prescriptions: pre-post study.
April 22, 2020
Slovis BH, Kairys J, Babula B, et al. Discrepancies in written versus calculated durations in opioid
prescriptions: pre-post study. JMIR Med Inform. 2020;8(3). doi:10.2196/16199.
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