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psnet.ahrq.gov/node/43331/psn-pdf
July 09, 2014 - Open wide: looking into the safety culture of dental
school clinics.
July 9, 2014
Ramoni R, Walji MF, Tavares A, et al. Open wide: looking into the safety culture of dental school clinics. J
Dent Edu. 2014;78(5):745-756.
https://psnet.ahrq.gov/issue/open-wide-looking-safety-culture-dental-school-clinics
Researche…
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psnet.ahrq.gov/node/73379/psn-pdf
June 09, 2021 - How medical jargon can make COVID health disparities
even worse.
June 9, 2021
Kritz F. Health Shots. National Public Radio; May 24, 2021.
https://psnet.ahrq.gov/issue/how-medical-jargon-can-make-covid-health-disparities-even-worse
Health literacy efforts address challenges related to both language and effecti…
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psnet.ahrq.gov/node/74756/psn-pdf
February 09, 2022 - Medication errors in overweight and obese pediatric
patients: a systematic review.
February 9, 2022
Procaccini D, Kim JM, Lobner K, et al. Medication errors in overweight and obese pediatric patients: a
systematic review. Jt Comm J Qual Patient Saf. 2022;48(3):154-164. doi:10.1016/j.jcjq.2021.12.005.
https://psnet…
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psnet.ahrq.gov/node/37401/psn-pdf
March 28, 2012 - Interventions for preventing falls in acute- and chronic-
care hospitals: a systematic review and meta-analysis.
March 28, 2012
Coussement J, De Paepe L, Schwendimann R, et al. Interventions for preventing falls in acute- and
chronic-care hospitals: a systematic review and meta-analysis. J Am Geriatr Soc. 2008;56(1…
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psnet.ahrq.gov/node/38276/psn-pdf
December 10, 2008 - Addressing delays in medication administration for
patients transferred from the hospital to the nursing
home: a pilot quality improvement project.
December 10, 2008
Ward KT, Bates-Jensen B, Eslami MS, et al. Addressing delays in medication administration for patients
transferred from the hospital to the nursing h…
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psnet.ahrq.gov/node/842431/psn-pdf
January 11, 2023 - Confronting racism in pediatric care.
January 11, 2023
Danielson B. Confronting racism in pediatric care. Health Affairs. 2022;41(11):1681-1685.
doi:10.1377/hlthaff.2022.01157.
https://psnet.ahrq.gov/issue/confronting-racism-pediatric-care
Racism is a patient safety issue that is gaining the increased attention ne…
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psnet.ahrq.gov/node/41826/psn-pdf
June 03, 2013 - Effects of an enhanced discharge planning intervention
for hospitalized older adults: a randomized trial.
June 3, 2013
Altfeld SJ, Shier GE, Rooney M, et al. Effects of an enhanced discharge planning intervention for
hospitalized older adults: a randomized trial. Gerontologist. 2013;53(3):430-40. doi:10.1093/geront…
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psnet.ahrq.gov/node/45586/psn-pdf
November 02, 2016 - Antimicrobial stewardship and patient safety.
November 2, 2016
Zukowski CM. Antimicrobial Stewardship and Patient Safety. AORN J. 2016;104(4):354-356.
doi:10.1016/j.aorn.2016.08.002.
https://psnet.ahrq.gov/issue/antimicrobial-stewardship-and-patient-safety
Antimicrobial stewardship has been highlighted as a strate…
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psnet.ahrq.gov/node/39185/psn-pdf
January 06, 2010 - Use of colour-coded labels for intravenous high-risk
medications and lines to improve patient safety.
January 6, 2010
Porat N, Bitan Y, Shefi D, et al. Use of colour-coded labels for intravenous high-risk medications and lines
to improve patient safety. Qual Saf Health Care. 2009;18(6):505-9. doi:10.1136/qshc.2007.…
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psnet.ahrq.gov/node/74276/psn-pdf
January 19, 2022 - Guideline for Prevention of Unintentionally Retained
Surgical Items.
January 19, 2022
Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6.
doi:10.1002/aorn.13579.
https://psnet.ahrq.gov/issue/guideline-prevention-unintentionally-retained-surgical-items
Retained su…
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psnet.ahrq.gov/node/42985/psn-pdf
February 26, 2014 - Confusion—specimen mix-up in dermatopathology and
measures to prevent and detect it.
February 26, 2014
Weyers W. Confusion-specimen mix-up in dermatopathology and measures to prevent and detect it.
Dermatol Pract Concept. 2014;4(1):27-42. doi:10.5826/dpc.0401a04.
https://psnet.ahrq.gov/issue/confusion-specimen-mix…
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psnet.ahrq.gov/node/50809/psn-pdf
January 15, 2020 - Electronic Health Record (EHR) Safety and Usability: See
What We Mean.
January 15, 2020
MedStar Health National Center for Human Factors in Healthcare.
https://psnet.ahrq.gov/issue/electronic-health-record-ehr-safety-and-usability-see-what-we-mean
Electronic health records (EHR) optimize information functions in c…
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psnet.ahrq.gov/node/42128/psn-pdf
August 15, 2013 - Computerized prescriber order entry and opportunities
for medication errors: comparison to tradition paper-
based order entry.
August 15, 2013
Jozefczyk KG, Kennedy WK, Lin MJ, et al. Computerized prescriber order entry and opportunities for
medication errors: comparison to tradition paper-based order entry. J Pha…
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psnet.ahrq.gov/node/45801/psn-pdf
August 03, 2017 - Overcoming diagnostic errors in medical practice.
August 3, 2017
Bordini BJ, Stephany A, Kliegman RM. Overcoming Diagnostic Errors in Medical Practice. J Pediatr.
2017;185. doi:10.1016/j.jpeds.2017.02.065.
https://psnet.ahrq.gov/issue/overcoming-diagnostic-errors-medical-practice
This commentary describes a progra…
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psnet.ahrq.gov/node/858323/psn-pdf
December 13, 2023 - Some doctors are ditching the scale, saying focusing on
weight drives misdiagnoses.
December 13, 2023
O'Neill E. Health Shots. National Public Radio. December 2, 2023.
https://psnet.ahrq.gov/issue/some-doctors-are-ditching-scale-saying-focusing-weight-drives-misdiagnoses
Inordinate focus on one element o…
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psnet.ahrq.gov/node/42235/psn-pdf
June 03, 2013 - Surgical safety checklist: implementation in an
ambulatory surgical facility.
June 3, 2013
Morgan PJ, Cunningham L, Mitra S, et al. Surgical safety checklist: implementation in an ambulatory
surgical facility. Can J Anaesth. 2013;60(6):528-38. doi:10.1007/s12630-013-9916-8.
https://psnet.ahrq.gov/issue/surgical-sa…
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psnet.ahrq.gov/node/44358/psn-pdf
September 24, 2016 - Interruptions and medication administration in critical
care.
September 24, 2016
Bower R, Jackson C, Manning JC. Interruptions and medication administration in critical care. Nurs Crit
Care. 2015;20(4):183-95. doi:10.1111/nicc.12185.
https://psnet.ahrq.gov/issue/interruptions-and-medication-administration-critical…
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psnet.ahrq.gov/node/44298/psn-pdf
July 08, 2015 - Preparing challenging medications for barcode scanning.
July 8, 2015
Waxlax TJ. Preparing challenging medications for barcode scanning. Am J Health Syst Pharm.
2015;72(13):1089-90. doi:10.2146/ajhp140454.
https://psnet.ahrq.gov/issue/preparing-challenging-medications-barcode-scanning
Barcode scanning can reduce me…
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psnet.ahrq.gov/node/60288/psn-pdf
April 29, 2020 - Do some surgical implants do more harm than good?
April 29, 2020
Groopman J. New Yorker Online. April 13, 2020.
https://psnet.ahrq.gov/issue/do-some-surgical-implants-do-more-harm-good
Medical devices support quality of life but must be designed appropriately and managed carefully to ensure
safety over time.…
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psnet.ahrq.gov/node/46943/psn-pdf
November 16, 2018 - A piece of my mind. The art of constructive worrying.
November 16, 2018
John CC. The Art of Constructive Worrying. JAMA. 2018;319(22):2273-2274. doi:10.1001/jama.2018.6670.
https://psnet.ahrq.gov/issue/piece-my-mind-art-constructive-worrying
Both organizational culture and individual accountability are key to admit…