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psnet.ahrq.gov/node/72763/psn-pdf
February 17, 2021 - Apotex Corp. issues voluntary nationwide recall of
Enoxaparin Sodium Injection, USP due to mislabeling of
syringe barrel measurement markings.
February 17, 2021
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 3. 2021.
https://psnet.ahrq.gov/issue/apotex-corp-issues…
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psnet.ahrq.gov/node/73522/psn-pdf
July 21, 2021 - Federal speech rulings may embolden health care
workers to call out safety issues.
July 21, 2021
Meyer H. Kaiser Health News. July 9, 2021.
https://psnet.ahrq.gov/issue/federal-speech-rulings-may-embolden-health-care-workers-call-out-safety-
issues
Whistleblower protections are a key component to raising awarenes…
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psnet.ahrq.gov/node/44791/psn-pdf
January 13, 2016 - FDA Drug Safety Communication: FDA cautions about
dosing errors when switching between different oral
formulations of antifungal Noxafil (posaconazole); label
changes approved.
January 13, 2016
US Food and Drug Administration; FDA.
https://psnet.ahrq.gov/issue/fda-drug-safety-communication-fda-cautions-about-dosi…
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psnet.ahrq.gov/node/46813/psn-pdf
March 14, 2018 - Our other prescription drug problem.
March 14, 2018
Lembke A, Papac J, Humphreys K. Our Other Prescription Drug Problem. N Engl J Med. 2018;378(8):693-
695. doi:10.1056/NEJMp1715050.
https://psnet.ahrq.gov/issue/our-other-prescription-drug-problem
Unintended consequences can emerge when targeted strategies divert …
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psnet.ahrq.gov/node/48036/psn-pdf
July 10, 2019 - Can positivity promote safety? Psychological capital
development combats cynicism and unsafe behavior.
July 10, 2019
Stratman JL, Youssef-Morgan CM. Can positivity promote safety? Psychological capital development
combats cynicism and unsafe behavior. Safety Sci. 2019;116:13-25. doi:10.1016/j.ssci.2019.02.031.
htt…
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psnet.ahrq.gov/node/45403/psn-pdf
September 21, 2016 - 'Superbug' scourge spreads as U.S. fails to track rising
human toll.
September 21, 2016
McNeill R, Nelson DJ, Abutaleb Y. Reuters Investigation. September 7, 2016.
https://psnet.ahrq.gov/issue/superbug-scourge-spreads-us-fails-track-rising-human-toll
Antimicrobial resistance is a pervasive threat to patient safety…
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psnet.ahrq.gov/node/37547/psn-pdf
February 20, 2008 - Intensive care unit nurses' perceptions of safety after a
highly specific safety intervention.
February 20, 2008
Elder NC, Brungs SM, Nagy M, et al. Intensive care unit nurses' perceptions of safety after a highly specific
safety intervention. Qual Saf Health Care. 2008;17(1):25-30. doi:10.1136/qshc.2006.021949.
h…
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psnet.ahrq.gov/node/47271/psn-pdf
August 08, 2018 - NAM Action Collaborative on Countering the U.S. Opioid
Epidemic.
August 8, 2018
National Academy of Medicine; Aspen Institute.
https://psnet.ahrq.gov/issue/nam-action-collaborative-countering-us-opioid-epidemic
Despite increased awareness regarding the public health impacts of opioid misuse and overdose in the
Un…
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psnet.ahrq.gov/node/35635/psn-pdf
June 24, 2010 - Patient safety problems in adolescent medical care.
June 24, 2010
Woods D, Holl JL, Klein JD, et al. Patient safety problems in adolescent medical care. J Adolesc Health.
2006;38(1):5-12.
https://psnet.ahrq.gov/issue/patient-safety-problems-adolescent-medical-care
Using data from the Colorado and Utah Medical Prac…
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psnet.ahrq.gov/node/34914/psn-pdf
February 27, 2009 - Drug error in anaesthetic practice: a review of 896 reports
from the Australian Incident Monitoring Study database.
February 27, 2009
Abeysekera A, Bergman IJ, Kluger MT, et al. Drug error in anaesthetic practice: a review of 896 reports
from the Australian Incident Monitoring Study database. Anaesthesia. 2005;60(3…
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psnet.ahrq.gov/node/866809/psn-pdf
September 25, 2024 - Stop the line: interventions to prevent retained surgical
items.
September 25, 2024
Angelilli S. Stop the line: interventions to prevent retained surgical items. AORN J. 2024;120(2):71-81.
doi:10.1002/aorn.14190.
https://psnet.ahrq.gov/issue/stop-line-interventions-prevent-retained-surgical-items
Retained surgica…
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psnet.ahrq.gov/node/46808/psn-pdf
February 14, 2018 - Anesthesia medication handling needs a new vision.
February 14, 2018
Grigg EB, Roesler A. Anesthesia Medication Handling Needs a New Vision. Anesth Analg.
2018;126(1):346-350. doi:10.1213/ANE.0000000000002521.
https://psnet.ahrq.gov/issue/anesthesia-medication-handling-needs-new-vision
Anesthesiology has been a le…
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psnet.ahrq.gov/node/46671/psn-pdf
June 25, 2018 - Twelve tips for embedding human factors and
ergonomics principles in healthcare education.
June 25, 2018
Vosper H, Hignett S, Bowie P. Twelve tips for embedding human factors and ergonomics principles in
healthcare education. Med Teach. 2017;40(4):357-363. doi:10.1080/0142159x.2017.1387240.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/853071/psn-pdf
August 30, 2023 - A natural language processing approach to categorise
contributing factors from patient safety event reports.
August 30, 2023
Tabaie A, Sengupta S, Pruitt ZM, et al. BMJ Health Care Inform. 2023;30(1):e100731.
https://psnet.ahrq.gov/issue/natural-language-processing-approach-categorise-contributing-factors-patient-
…
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psnet.ahrq.gov/node/852452/psn-pdf
August 16, 2023 - Value assessment of deprescribing interventions:
suggestions for improvement.
August 16, 2023
Hung A, Wang J, Moriarty F, et al. Value assessment of deprescribing interventions: suggestions for
improvement. J Am Geriatr Soc. 2023;71(6):2023-2027. doi:10.1111/jgs.18298.
https://psnet.ahrq.gov/issue/value-assessment…
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psnet.ahrq.gov/node/43103/psn-pdf
April 02, 2014 - Ten Years After Keeping Patients Safe: Have Nurses'
Work Environments Been Transformed?
April 2, 2014
Princeton, NJ: Robert Wood Johnson Foundation. Washington, DC: George Washington University School
of Nursing. March 14, 2014;22:1-8.
https://psnet.ahrq.gov/issue/ten-years-after-keeping-patients-safe-have-nurses-…
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psnet.ahrq.gov/node/847536/psn-pdf
April 12, 2023 - Racism and electronic health records (EHRs):
perspectives for research and practice.
April 12, 2023
Emani S, Rodriguez JA, Bates DW. Racism and electronic health records (EHRs): perspectives for
research and practice. J Am Med Inform Assoc. 2023;30(5):995-999. doi:10.1093/jamia/ocad023.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/46058/psn-pdf
October 23, 2018 - Centers for Disease Control and Prevention Guideline for
the Prevention of Surgical Site Infection, 2017.
October 23, 2018
Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline
for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8).
doi:10.100…
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psnet.ahrq.gov/node/39773/psn-pdf
August 18, 2010 - Preventing potentially inappropriate medication use in
hospitalized older patients with a computerized provider
order entry warning system.
August 18, 2010
Mattison MLP, Afonso KA, Ngo LH, et al. Preventing potentially inappropriate medication use in
hospitalized older patients with a computerized provider order e…
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psnet.ahrq.gov/node/41701/psn-pdf
September 26, 2019 - The CUSP Method
September 26, 2019
The CUSP Method.
https://psnet.ahrq.gov/issue/cusp-method
The Comprehensive Unit-based Safety Program (CUSP), originally developed at Johns Hopkins Hospital
by Dr. Peter Pronovost and colleagues, has been instrumental in driving patient safety improvement in
several landmark pat…