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psnet.ahrq.gov/node/73895/psn-pdf
September 29, 2021 - Open Notes shines light on errors in patient medical
records — will the new rule lead to a flood of correction
requests?
September 29, 2021
Clark C. MedPage Today. September 14, 2021.
https://psnet.ahrq.gov/issue/open-notes-shines-light-errors-patient-medical-records-will-new-rule-lead-
flood-correctio…
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psnet.ahrq.gov/node/840143/psn-pdf
January 01, 2024 - Criteria for the selection of paediatric patients susceptible
to reconciliation error.
November 16, 2022
Iturgoyen Fuentes DP, Meneses Mangas C, Cuervas Mons Vendrell M. Criteria for the selection of
paediatric patients susceptible to reconciliation error. Eur J Hosp Pharm. 2024;31(3):234-239.
doi:10.1136/ejhpharm…
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psnet.ahrq.gov/node/860732/psn-pdf
April 16, 2024 - Retained Swabs Following Invasive Procedures: Themes
Identified from a Review of NHS Serious Incident Reports.
April 16, 2024
Dorset, UK: Health Services Safety Investigations Body; April 2024.
https://psnet.ahrq.gov/issue/retained-swabs-following-invasive-procedures-themes-identified-review-nhs-
serious-incident
…
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psnet.ahrq.gov/node/43909/psn-pdf
March 11, 2015 - Summary and frequency of barriers to adoption of CPOE
in the US.
March 11, 2015
Kruse CS, Goetz K. Summary and frequency of barriers to adoption of CPOE in the U.S. J Med Syst.
2015;39(2):15. doi:10.1007/s10916-015-0198-2.
https://psnet.ahrq.gov/issue/summary-and-frequency-barriers-adoption-cpoe-us
Although compu…
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psnet.ahrq.gov/node/44037/psn-pdf
March 14, 2018 - Pediatric medication safety in the emergency department.
March 14, 2018
Benjamin L, Frush K, Shaw KN, et al. Pediatric Medication Safety in the Emergency Department. Ann
Emerg Med. 2018;71(3):e17-e24. doi:10.1016/j.annemergmed.2017.12.013.
https://psnet.ahrq.gov/issue/pediatric-medication-safety-emergency-departmen…
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psnet.ahrq.gov/node/44568/psn-pdf
October 21, 2015 - Developing and deploying a patient safety program in a
large health care delivery system: you can't fix what you
don't know about.
October 21, 2015
Bagian JP, Lee C, Gosbee J, et al. Developing and deploying a patient safety program in a large health
care delivery system: you can't fix what you don't know about. J…
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psnet.ahrq.gov/node/47953/psn-pdf
January 01, 2021 - Impact of medication reviews delivered by community
pharmacist to elderly patients on polypharmacy: a meta-
analysis of randomized controlled trials.
June 26, 2019
Tasai S, Kumpat N, Dilokthornsakul P, et al. Impact of Medication Reviews Delivered by Community
Pharmacist to Elderly Patients on Polypharmacy: A Meta…
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psnet.ahrq.gov/node/837432/psn-pdf
June 15, 2022 - Adopt strategies to manage look-alike and/or sound-alike
medication name mix-ups.
June 15, 2022
ISMP Medication Safety Alert! Acute care edition. June 2, 2022;27(11):1-4.
https://psnet.ahrq.gov/issue/adopt-strategies-manage-look-alike-andor-sound-alike-medication-name-mix-
ups
Minimizing look-alike/sound-alike me…
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psnet.ahrq.gov/node/43855/psn-pdf
April 15, 2016 - Perioperative safety in plastic surgery: is the World
Health Organization checklist useful in a broad practice?
April 15, 2016
Biskup N, Workman AD, Kutzner E, et al. Perioperative Safety in Plastic Surgery: Is the World Health
Organization Checklist Useful in a Broad Practice? Ann Plast Surg. 2016;76(5):550-5.
do…
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psnet.ahrq.gov/node/46580/psn-pdf
June 25, 2018 - Out-of-hospital pediatric patient safety events: results of
the CSI chart review.
June 25, 2018
Meckler G, Hansen M, Lambert W, et al. Out-of-Hospital Pediatric Patient Safety Events: Results of the CSI
Chart Review. Prehosp Emerg Care. 2018;22(3):290-299. doi:10.1080/10903127.2017.1371261.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/43383/psn-pdf
August 13, 2014 - Risk factors for retained surgical items: a meta-analysis
and proposed risk stratification system.
August 13, 2014
Moffatt-Bruce SD, Cook CH, Steinberg SM, et al. Risk factors for retained surgical items: a meta-analysis
and proposed risk stratification system. J Surg Res. 2014;190(2):429-36. doi:10.1016/j.jss.2014…
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psnet.ahrq.gov/node/44470/psn-pdf
October 13, 2015 - Workplace training for senior trainees: a systematic
review and narrative synthesis of current approaches to
promote patient safety.
October 13, 2015
Walton M, Harrison R, Burgess A, et al. Workplace training for senior trainees: a systematic review and
narrative synthesis of current approaches to promote patient …
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psnet.ahrq.gov/node/838325/psn-pdf
October 12, 2022 - Comprehensive Healthcare Inspection Summary Report:
Evaluation of Care Coordination in Veterans Health
Administration Facilities, Fiscal Year 2021.
October 12, 2022
Washington, DC: VA Office of the Inspector General; September 15, 2022. Report no. 22-00815-232.
https://psnet.ahrq.gov/issue/comprehensive-healthcare…
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psnet.ahrq.gov/node/846453/psn-pdf
March 02, 2021 - The dollar or disease burden: caps on healthcare
spending may save money, but at what "cost" to
patients?
March 2, 2021
Ciarametaro M, Houghton K, Wamble D, et al. The dollar or disease burden: caps on healthcare spending
may save money, but at what "cost" to patients? Value Health. 2021;24(3):388-396.
doi:10.101…
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psnet.ahrq.gov/node/837338/psn-pdf
June 08, 2022 - Healthcare-related infections within nursing homes
(NHS): a qualitative study of care practices based on a
systemic approach.
June 8, 2022
Lefosse G, Rasero L, Bellandi T, et al. Healthcare-related infections within nursing homes (NHS): A
qualitative study of care practices based on a systemic approach. J Patient …
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psnet.ahrq.gov/node/44799/psn-pdf
July 11, 2017 - Unintended Consequences: New Problems and New
Solutions.
July 11, 2017
Lehmann CU, Sroussi B, Jaulent MC, eds. Yearb Med Inform. 2016;1:1-271.
https://psnet.ahrq.gov/issue/unintended-consequences-new-problems-and-new-solutions
Unexpected effects associated with implementation and use of health information technolo…
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psnet.ahrq.gov/node/45795/psn-pdf
May 24, 2017 - Patient Hand-Off iNitiation and Evaluation (PHONE) study:
a randomized trial of patient handoff methods.
May 24, 2017
Clanton J, Gardner A, Subichin M, et al. Patient Hand-Off iNitiation and Evaluation (PHONE) study: A
randomized trial of patient handoff methods. Am J Surg. 2017;213(2):299-306.
doi:10.1016/j.amjsu…
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psnet.ahrq.gov/node/47729/psn-pdf
April 10, 2019 - Reclaiming the systems approach to paediatric safety.
April 10, 2019
Cheung R, Roland D, Lachman P. Reclaiming the systems approach to paediatric safety. Arch Dis Child.
2019;104(12):1130-1133. doi:10.1136/archdischild-2018-316401.
https://psnet.ahrq.gov/issue/reclaiming-systems-approach-paediatric-safety
Children…
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psnet.ahrq.gov/node/44742/psn-pdf
January 06, 2016 - A piece of my mind. From shame to guilt to love.
January 6, 2016
Pronovost P, Bienvenu J. A piece of my mind. From shame to guilt to love. JAMA. 2015;314(23):2507-
2508. doi:10.1001/jama.2015.11521.
https://psnet.ahrq.gov/issue/piece-my-mind-shame-guilt-love
While numerous studies have examined the psychological i…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc.html
November 01, 2018 - Improving Patient Safety in Long-Term Care Facilities
Training Modules
Detecting and promptly reporting changes in a nursing home resident's condition are critical for ensuring the resident's well-being and safety. Such changes may represent a patient safety problem, and they can be a signal tha…