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psnet.ahrq.gov/node/44317/psn-pdf
August 19, 2015 - Use of in-situ simulation to investigate latent safety
threats prior to opening a new emergency department.
August 19, 2015
Medwid K, Smith SW, Gang M. Use of in-situ simulation to investigate latent safety threats prior to opening
a new emergency department. Safety Sci. 2015;77:19-24. doi:10.1016/j.ssci.2015.03.01…
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psnet.ahrq.gov/node/50829/psn-pdf
January 22, 2020 - How one medical checkup can snowball into a ‘cascade’
of tests, causing more harm than good.
January 22, 2020
Ganguli I. Washington Post. January 5, 2020.
https://psnet.ahrq.gov/issue/how-one-medical-checkup-can-snowball-cascade-tests-causing-more-harm-
good
Overdiagnosis and uncertainty can result in a range of …
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psnet.ahrq.gov/node/50744/psn-pdf
December 18, 2019 - EMS crews brought patients to the hospital with
misplaced breathing tubes. None of them survived
December 18, 2019
Arditi L. Peoples Public Radio. December 3, 2019.
https://psnet.ahrq.gov/issue/ems-crews-brought-patients-hospital-misplaced-breathing-tubes-none-them-
survived
Emergency medical services are often p…
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psnet.ahrq.gov/node/837340/psn-pdf
June 08, 2022 - Wellbeing, burnout, and safe practice among healthcare
professionals: predictive influences of mindfulness,
values, and self-compassion.
June 8, 2022
Prudenzi A, D. Graham C, Flaxman PE, et al. Wellbeing, burnout, and safe practice among healthcare
professionals: predictive influences of mindfulness, values, and s…
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psnet.ahrq.gov/node/46758/psn-pdf
April 12, 2019 - Association of hospitalist years of experience with
mortality in the hospitalized Medicare population.
April 12, 2019
Goodwin JS, Salameh H, Zhou J, et al. Association of Hospitalist Years of Experience With Mortality in the
Hospitalized Medicare Population. JAMA Intern Med. 2017;178(2). doi:10.1001/jamainternmed.2…
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psnet.ahrq.gov/node/46795/psn-pdf
March 28, 2018 - Systematic review and meta-analysis of the effectiveness
of pharmacist-led medication reconciliation in the
community after hospital discharge.
March 28, 2018
McNab D, Bowie P, Ross A, et al. Systematic review and meta-analysis of the effectiveness of pharmacist-
led medication reconciliation in the community afte…
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psnet.ahrq.gov/node/60286/psn-pdf
April 29, 2020 - With Covid-19 delaying routine care, chronic disease
startups brace for a slew of complications.
April 29, 2020
Brodwin E. STAT. April 14, 2020.
https://psnet.ahrq.gov/issue/covid-19-delaying-routine-care-chronic-disease-startups-brace-slew-
complications
Patients with cancer and other chronic disorder treatment …
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psnet.ahrq.gov/node/42673/psn-pdf
October 30, 2013 - Clinical evaluation of the ADE scorecards as a decision
support tool for adverse drug event analysis and
medication safety management.
October 30, 2013
Hackl WO, Ammenwerth E, Marcilly R, et al. Clinical evaluation of the ADE scorecards as a decision
support tool for adverse drug event analysis and medication safe…
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psnet.ahrq.gov/node/43105/psn-pdf
April 02, 2014 - Application of surgical safety standards to robotic
surgery: five principles of ethics for nonmaleficence.
April 2, 2014
Larson JA, Johnson MH, Bhayani SB. Application of surgical safety standards to robotic surgery: five
principles of ethics for nonmaleficence. J Am Coll Surg. 2014;218(2):290-3.
doi:10.1016/j.jam…
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psnet.ahrq.gov/node/72584/psn-pdf
December 16, 2020 - Hidden medication loss when using a primary
administration set for small-volume intermittent infusions.
December 16, 2020
ISMP Medication Safety Alert! Acute care edition. December 3, 2020;25(24).
https://psnet.ahrq.gov/issue/hidden-medication-loss-when-using-primary-administration-set-small-volume-
intermittent
…
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psnet.ahrq.gov/curated-library/patient-and-family-engagement-long-term-care
April 10, 2024 - Johnson about The Role of Patient's Family In Reducing Harm
Beverley H.
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psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care
September 30, 2011 - Schematic Illustrating Elements of the Modified Kost Taxonomy for Reducing Errors in Point-of-care Testing
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
January 01, 2019 - Identifying and reducing medication errors in psychiatry: creating a culture of safety through the use
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psnet.ahrq.gov/issue/national-implementation-project-prevent-catheter-associated-urinary-tract-infection-nursing
April 05, 2017 - Study
Classic
A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents.
Citation Text:
Mody L, Greene T, Meddings J, et al. A National Implementation Project to Prevent Catheter-Associated Urinary Tract I…
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psnet.ahrq.gov/issue/distinguishing-high-performing-low-performing-hospitals-severe-maternal-morbidity-focus
June 01, 2022 - Study
Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on quality and equity.
Citation Text:
Howell EA, Sofaer S, Balbierz A, et al. Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on q…
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psnet.ahrq.gov/issue/exploring-roots-unintended-safety-threats-associated-introduction-hospital-eprescribing
December 21, 2022 - Study
Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study.
Citation Text:
Mozaffar H, Cresswell K, Williams R, et al. Exploring the roots of unintended…
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psnet.ahrq.gov/issue/patient-doctor-continuity-and-diagnosis-cancer-electronic-medical-records-study-general
September 11, 2019 - Study
Patient–doctor continuity and diagnosis of cancer: electronic medical records study in general practice.
Citation Text:
Ridd MJ, Ferreira DLS, Montgomery AA, et al. Patient-doctor continuity and diagnosis of cancer: electronic medical records study in general practice. Br J Gen Pra…
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psnet.ahrq.gov/issue/detectability-medication-errors-stoppstart-based-medication-review-older-people-prior
August 18, 2021 - Study
Detectability of medication errors with a STOPP/START-based medication review in older people prior to a potentially preventable drug-related hospital admission.
Citation Text:
Sallevelt BTGM, Egberts TCG, Huibers CJA, et al. Detectability of medication errors with a STOPP/START-ba…
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psnet.ahrq.gov/issue/use-electronic-clinical-decision-support-system-primary-care-assess-inappropriate
October 21, 2020 - Study
Use of an electronic clinical decision support system in primary care to assess inappropriate polypharmacy in young seniors with multimorbidity: observational, descriptive, cross-sectional study
Citation Text:
Rogero-Blanco E, Lopez-Rodriguez JA, Sanz-Cuesta T, et al. Use of an ele…
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psnet.ahrq.gov/issue/performance-trigger-tool-detecting-drug-related-hospital-admissions-older-people-analysis
December 21, 2022 - Study
Performance of a trigger tool for detecting drug-related hospital admissions in older people: analysis from the OPERAM trial.
Citation Text:
Zerah L, Henrard S, Thevelin S, et al. Performance of a trigger tool for detecting drug-related hospital admissions in older people: analysis…