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psnet.ahrq.gov/node/851350/psn-pdf
July 12, 2023 - A scoping review of legibility of hand-written
prescriptions and drug-orders: the writing on the wall.
July 12, 2023
Ariaga A, Balzan D, Falzon S, et al. A scoping review of legibility of hand-written prescriptions and drug-
orders: the writing on the wall. Expert Rev Clin Pharmacol. 2023;16(7):617-621.
doi:10.108…
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psnet.ahrq.gov/node/44207/psn-pdf
August 21, 2018 - U.S. compounding pharmacy-related outbreaks, 2001--
2013: public health and patient safety lessons learned.
August 21, 2018
Shehab N, Brown MN, Kallen AJ, et al. U.S. compounding pharmacy-related outbreaks, 2001--2013: public
health and patient safety lessons learned. J Patient Saf. 2018;14(3):164-173.
doi:10.1097…
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psnet.ahrq.gov/node/45192/psn-pdf
December 04, 2016 - Evidence summary and recommendations for improved
communication during care transitions.
December 4, 2016
Jackson PD, Biggins MS, Cowan L, et al. Evidence Summary and Recommendations for Improved
Communication during Care Transitions. Rehabil Nurs. 2016;41(3):135-48. doi:10.1002/rnj.230.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/46566/psn-pdf
June 25, 2018 - A systematic review of interventions to follow-up test
results pending at discharge.
June 25, 2018
Darragh PJ, Bodley T, Orchanian-Cheff A, et al. A Systematic Review of Interventions to Follow-Up Test
Results Pending at Discharge. J Gen Intern Med. 2018;33(5):750-758. doi:10.1007/s11606-017-4290-9.
https://psnet.…
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psnet.ahrq.gov/node/837972/psn-pdf
September 01, 2022 - Patient safety: where to aim when zero harm is not the
target-a case for learning and resilience.
September 1, 2022
Stockwell DC, Kayes DC, Thomas EJ. Patient safety: where to aim when zero harm is not the target-a case
for learning and resilience. J Patient Saf. 2022;18(5):e877-e882. doi:10.1097/pts.00000000000009…
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psnet.ahrq.gov/node/47121/psn-pdf
August 08, 2018 - Assessment of programs aimed to decrease or prevent
mistreatment of medical trainees.
August 8, 2018
Mazer LM, Bereknyei Merrell S, Hasty BN, et al. Assessment of Programs Aimed to Decrease or Prevent
Mistreatment of Medical Trainees. JAMA Netw Open. 2018;1(3):e180870.
doi:10.1001/jamanetworkopen.2018.0870.
https…
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psnet.ahrq.gov/node/866202/psn-pdf
July 24, 2024 - Medication Without Harm - How Digital Healthcare Tools
Can Support Providers and Improve Patient Safety.
June 26, 2024
Agency for Healthcare Research and Quality. July 24, 2024.
https://psnet.ahrq.gov/issue/medication-without-harm-how-digital-healthcare-tools-can-support-providers-
and-improve
Medication errors a…
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psnet.ahrq.gov/node/43799/psn-pdf
January 07, 2015 - Omission of high-alert medications: a hidden danger.
January 7, 2015
Grissinger M, Alghamdi D. PA-PSRS Patient Saf Advis. December 2014;11:149-155.
https://psnet.ahrq.gov/issue/omission-high-alert-medications-hidden-danger
Analyzing incidents reported over a 4-month period, this article reveals that 21% of 2700 med…
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psnet.ahrq.gov/node/39602/psn-pdf
August 09, 2013 - Postoperative handover: problems, pitfalls, and
prevention of error.
August 9, 2013
Nagpal K, Arora S, Abboudi M, et al. Postoperative handover: problems, pitfalls, and prevention of error.
Ann Surg. 2010;252(1):171-6. doi:10.1097/SLA.0b013e3181dc3656.
https://psnet.ahrq.gov/issue/postoperative-handover-problems-p…
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psnet.ahrq.gov/node/60616/psn-pdf
June 24, 2020 - Nurse-reported bullying and documented adverse patient
events: an exploratory study in a US Hospital.
June 24, 2020
Arnetz JE, Neufcourt L, Sudan S, et al. Nurse-reported bullying and documented adverse patient events:
an exploratory study in a US Hospital. J Nurs Care Qual. 2020;35(3):206-212.
doi:10.1097/ncq.000…
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psnet.ahrq.gov/node/860722/psn-pdf
January 17, 2024 - Ten years of incident reports on in-hospital cardiac arrest
- Are they useful for improvements?
January 17, 2024
Djärv T. Ten years of incident reports on in-hospital cardiac arrest – Are they useful for improvements?
Resusc Plus. 2023;17:100525. doi:10.1016/j.resplu.2023.100525.
https://psnet.ahrq.gov/issue/ten-y…
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psnet.ahrq.gov/node/44563/psn-pdf
October 21, 2015 - The effect of staff nurses' shift length and fatigue on
patient safety and nurses' health: from the National
Association of Neonatal Nurses.
October 21, 2015
Samra HA, Smith BA. The Effect of Staff Nurses' Shift Length and Fatigue on Patient Safety and Nurses'
Health: From the National Association of Neonatal Nurs…
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psnet.ahrq.gov/node/42954/psn-pdf
December 04, 2016 - "Please describe from your point of view a typical case of
an error in palliative care": qualitative data from an
exploratory cross-sectional survey study among palliative
care professionals.
December 4, 2016
Dietz I, Plog A, Jox RJ, et al. "Please describe from your point of view a typical case of an error in pal…
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psnet.ahrq.gov/node/851645/psn-pdf
July 26, 2023 - Anticoagulation-associated adverse drug events in
hospitalized patients across two time periods.
July 26, 2023
Fanikos J, Tawfik Y, Almheiri D, et al. Anticoagulation-associated adverse drug events in hospitalized
patients across two time periods. Am J Med. 2023;136(9):927-936. doi:10.1016/j.amjmed.2023.05.013.
ht…
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psnet.ahrq.gov/node/45919/psn-pdf
July 05, 2017 - Managing the patient identification crisis in healthcare
and laboratory medicine.
July 5, 2017
Lippi G, Mattiuzzi C, Bovo C, et al. Managing the patient identification crisis in healthcare and laboratory
medicine. Clin Biochem. 2017;50(10-11):562-567. doi:10.1016/j.clinbiochem.2017.02.004.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/855421/psn-pdf
November 15, 2023 - Informatics tools in deprescribing and medication
optimization in older adults: development and
dissemination of VIONE methodology in a high reliability
organization.
November 15, 2023
Winter SG, Sedgwick C, Wallace-Lacey A, et al. Informatics tools in deprescribing and medication
optimization in older adults: de…
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psnet.ahrq.gov/node/45851/psn-pdf
February 22, 2017 - Eight years of decreased methicillin-resistant
Staphylococcus aureus health care–associated infections
associated with a Veterans Affairs prevention initiative.
February 22, 2017
Evans ME, Kralovic SM, Simbartl LA, et al. Eight years of decreased methicillin-resistant Staphylococcus
aureus health care-associated i…
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psnet.ahrq.gov/node/74153/psn-pdf
December 08, 2021 - The benefits and harms of open notes in mental health: a
Delphi survey of international experts.
December 8, 2021
Blease CR, Kharko A, Hägglund M, et al. The benefits and harms of open notes in mental health: a Delphi
survey of international experts. PLoS ONE. 2021;16(10):e0258056. doi:10.1371/journal.pone.0258056.…
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psnet.ahrq.gov/node/47607/psn-pdf
February 13, 2019 - Infection prevention in long-term care: re-evaluating the
system using a human factors engineering approach.
February 13, 2019
Katz MJ, Gurses AP. Infection prevention in long-term care: re-evaluating the system using a human
factors engineering approach. Infect Control Hosp Epidemiol. 2019;40(1):95-99. doi:10.1017…
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psnet.ahrq.gov/node/867192/psn-pdf
November 20, 2024 - 2024 Network of Patient Safety Databases Chartbook:
Medication and Other Substance Events.
November 20, 2024
2024 Network Of Patient Safety Databases Chartbook: Medication And Other Substance Events. Rockville,
MD: Agency for Healthcare Research and Quality; 2024. AHRQ Pub. No. 24-0088
https://psnet.ahrq.gov/issue…