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psnet.ahrq.gov/node/43952/psn-pdf
March 04, 2015 - Improving resident morning sign-out by use of daily
events reports.
March 4, 2015
Nabors C, Patel D, Khera S, et al. Improving resident morning sign-out by use of daily events reports. J
Patient Saf. 2015;11(1):36-41. doi:10.1097/PTS.0b013e31829e4f56.
https://psnet.ahrq.gov/issue/improving-resident-morning-sign-ou…
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psnet.ahrq.gov/node/42961/psn-pdf
February 19, 2014 - Healthcare-associated infections: a national patient safety
problem and the coordinated response.
February 19, 2014
Jeeva RR, Wright D. Healthcare-associated infections: a national patient safety problem and the
coordinated response. Med Care. 2014;52(2 Suppl 1):S4-8. doi:10.1097/MLR.0b013e3182a54581.
https://psne…
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psnet.ahrq.gov/node/854265/psn-pdf
October 04, 2023 - Can AI help doctors come up with better diagnoses?
October 4, 2023
Landro L. Wall Street Journal. September 24, 2023.
https://psnet.ahrq.gov/issue/can-ai-help-doctors-come-better-diagnoses
Artificial intelligence (AI) is being considered as a strong contender in the effort to reduce harmful
diagnostic error, but c…
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psnet.ahrq.gov/node/849609/psn-pdf
May 31, 2023 - Impact of diagnostic checklists on the interpretation of
normal and abnormal electrocardiograms.
May 31, 2023
Staal J, Zegers R, Caljouw-Vos J, et al. Impact of diagnostic checklists on the interpretation of normal and
abnormal electrocardiograms. Diagnosis (Berl). 2022;10(2):121-129. doi:10.1515/dx-2022-0092.
htt…
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psnet.ahrq.gov/node/37262/psn-pdf
December 19, 2011 - Academic detailing to improve laboratory testing among
outpatient medication users.
December 19, 2011
Lafata JE, Gunter MJ, Hsu J, et al. Academic detailing to improve laboratory testing among outpatient
medication users. Med Care. 2007;45(10):966-72.
https://psnet.ahrq.gov/issue/academic-detailing-improve-laborat…
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psnet.ahrq.gov/node/36106/psn-pdf
May 27, 2011 - Evidence-based red cell transfusion in the critically ill:
quality improvement using computerized physician order
entry.
May 27, 2011
Rana R, Afessa B, Keegan MT, et al. Evidence-based red cell transfusion in the critically ill: quality
improvement using computerized physician order entry. Crit Care Med. 2006;34(7…
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psnet.ahrq.gov/node/46090/psn-pdf
December 22, 2018 - More than a tick box: medical checklist development,
design, and use.
December 22, 2018
Burian BK, Clebone A, Dismukes K, et al. More Than a Tick Box: Medical Checklist Development, Design,
and Use. Anesth Analg. 2018;126(1):223-232. doi:10.1213/ANE.0000000000002286.
https://psnet.ahrq.gov/issue/more-tick-box-medi…
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psnet.ahrq.gov/node/45547/psn-pdf
October 05, 2016 - Sick children face potentially deadly danger: medication
errors.
October 5, 2016
Furfaro H. Wall Street Journal. September 25, 2016.
https://psnet.ahrq.gov/issue/sick-children-face-potentially-deadly-danger-medication-errors
Medication errors in pediatric care are common in the hospital and at home. This newspaper…
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psnet.ahrq.gov/node/47289/psn-pdf
October 24, 2018 - ASHP guidelines on managing drug product shortages.
October 24, 2018
Fox ER, McLaughlin MM. ASHP guidelines on managing drug product shortages. Am J Health Syst Pharm.
2018;75(21):1742-1750. doi:10.2146/ajhp180441.
https://psnet.ahrq.gov/issue/ashp-guidelines-managing-drug-product-shortages
Drug shortages are a pe…
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psnet.ahrq.gov/node/72535/psn-pdf
December 02, 2020 - Learning from influenza vaccine errors to prepare for
COVID-19 vaccination campaigns.
December 2, 2020
ISMP Medication Safety Alert! Acute care edition. November 19, 2020;25(23):1-6.
https://psnet.ahrq.gov/issue/learning-influenza-vaccine-errors-prepare-covid-19-vaccination-campaigns
Safety professionals enco…
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psnet.ahrq.gov/node/73691/psn-pdf
September 08, 2021 - Pump up the volume: tips for increasing error reporting
and decreasing patient harm.
September 8, 2021
ISMP Medication Safety Alert! Acute care edition. August 26, 2021;26(17);1-5.
https://psnet.ahrq.gov/issue/pump-volume-tips-increasing-error-reporting-and-decreasing-patient-harm
Error reporting is an essen…
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psnet.ahrq.gov/node/39511/psn-pdf
November 02, 2010 - Prospective pilot intervention study to prevent medication
errors in drugs administered to children by mouth or
gastric tube: a programme for nurses, physicians and
parents.
November 2, 2010
Bertsche T, Bertsche A, Krieg E-M, et al. Prospective pilot intervention study to prevent medication errors
in drugs admini…
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psnet.ahrq.gov/node/60604/psn-pdf
June 17, 2020 - The limits of current A.I. in health care: patient safety
policing in hospitals.
June 17, 2020
Furrow BR. NE Univ Law Rev. 2020;12(1):1-55.
https://psnet.ahrq.gov/issue/limits-current-ai-health-care-patient-safety-policing-hospitals
Artificial intelligence (AI) has the potential to improve the use of big data to e…
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psnet.ahrq.gov/node/45923/psn-pdf
April 19, 2017 - Huddles and debriefings: improving communication on
labor and delivery.
April 19, 2017
McQuaid-Hanson E, Pian-Smith MCM. Huddles and Debriefings: Improving Communication on Labor and
Delivery. Anesthesiol Clin. 2017;35(1):59-67. doi:10.1016/j.anclin.2016.09.006.
https://psnet.ahrq.gov/issue/huddles-and-debriefings…
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psnet.ahrq.gov/node/43819/psn-pdf
July 16, 2015 - Intercepting wrong-patient orders in a computerized
provider order entry system.
July 16, 2015
Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider
order entry system. Ann Emerg Med. 2015;65(6):679-686.e1. doi:10.1016/j.annemergmed.2014.11.017.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/37754/psn-pdf
May 14, 2008 - Potentially inappropriate medication use in hospitalized
elders.
May 14, 2008
Rothberg MB, Pekow PS, Liu F, et al. Potentially inappropriate medication use in hospitalized elders. J
Hosp Med. 2008;3(2):91-102. doi:10.1002/jhm.290.
https://psnet.ahrq.gov/issue/potentially-inappropriate-medication-use-hospitalized-e…
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psnet.ahrq.gov/node/47645/psn-pdf
April 17, 2019 - When a nurse is prosecuted for a fatal medical mistake,
does it make medicine safer?
April 17, 2019
Gordon M. Health Shots. National Public Radio. April 10, 2019.
https://psnet.ahrq.gov/issue/when-nurse-prosecuted-fatal-medical-mistake-does-it-make-medicine-safer
Punitive responses to medical errors persist despit…
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psnet.ahrq.gov/node/60766/psn-pdf
August 05, 2020 - Dermatology faces a reckoning: lack of darker skin in
textbooks and journals harms care for patients of color.
August 5, 2020
McFarling UL. Stat. July 21, 2020.
https://psnet.ahrq.gov/issue/dermatology-faces-reckoning-lack-darker-skin-textbooks-and-journals-harms-
care-patients-color
Dermatologists rely on v…
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psnet.ahrq.gov/node/40985/psn-pdf
December 07, 2011 - Implementing the World Health Organization surgical
safety checklist: a model for future perioperative
initiatives.
December 7, 2011
Styer KA, Ashley SW, Schmidt I, et al. Implementing the World Health Organization surgical safety
checklist: a model for future perioperative initiatives. AORN J. 2011;94(6):590-8.
…
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psnet.ahrq.gov/node/836759/psn-pdf
April 06, 2022 - Diversion is a Threat to Patient Safety: Adopting Best
Practices.
March 16, 2022
Institute for Safe Medication Practices. April 6, 2022.
https://psnet.ahrq.gov/issue/diversion-threat-patient-safety-adopting-best-practices
Drug diversion can result in patient harm due to reduced medication availability, impai…