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psnet.ahrq.gov/node/46270/psn-pdf
April 16, 2018 - Impact of a restraint management bundle on restraint use
in an intensive care unit.
April 16, 2018
Hall DK, Zimbro KS, Maduro RS, et al. Impact of a Restraint Management Bundle on Restraint Use in an
Intensive Care Unit. J Nurs Care Qual. 2018;33(2):143-148. doi:10.1097/NCQ.0000000000000273.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/865661/psn-pdf
April 24, 2024 - Pay-for-performance and patient safety in acute care: a
systematic review.
April 24, 2024
Slawomirski L, Hensher M, Campbell JL, et al. Pay-for-performance and patient safety in acute care: a
systematic review. Health Policy. 2024;143:105051. doi:10.1016/j.healthpol.2024.105051.
https://psnet.ahrq.gov/issue/pay-pe…
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psnet.ahrq.gov/node/35575/psn-pdf
April 11, 2011 - Parental preferences for error disclosure, reporting, and
legal action after medical error in the care of their
children.
April 11, 2011
Hobgood C, Tamayo-Sarver JH, Elms A, et al. Parental preferences for error disclosure, reporting, and
legal action after medical error in the care of their children. Pediatrics. …
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psnet.ahrq.gov/node/46811/psn-pdf
May 17, 2018 - A surgical procedure grid for safety and operating room
communication in multisite surgery.
May 17, 2018
Insalaco LF, Spiegel JH. A Surgical Procedure Grid for Safety and Operating Room Communication in
Multisite Surgery. JAMA Facial Plast Surg. 2018;20(3):185-186. doi:10.1001/jamafacial.2017.2049.
https://psnet.a…
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psnet.ahrq.gov/node/60255/psn-pdf
April 22, 2020 - Discrepancies in written versus calculated durations in
opioid prescriptions: pre-post study.
April 22, 2020
Slovis BH, Kairys J, Babula B, et al. Discrepancies in written versus calculated durations in opioid
prescriptions: pre-post study. JMIR Med Inform. 2020;8(3). doi:10.2196/16199.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/47869/psn-pdf
April 17, 2019 - Minimizing Opioid Prescribing in Surgery (MOPiS)
initiative: an analysis of implementation barriers.
April 17, 2019
Coughlin JM, Shallcross ML, Schäfer WLA, et al. Minimizing Opioid Prescribing in Surgery (MOPiS)
Initiative: An Analysis of Implementation Barriers. J Surg Res. 2019;239:309-319.
doi:10.1016/j.jss.20…
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psnet.ahrq.gov/node/74097/psn-pdf
November 24, 2021 - Inattentional blindness in anesthesiology: a gorilla is
worth one thousand words.
November 24, 2021
De Cassai A, Negro S, Geraldini F, et al. Inattentional blindness in anesthesiology: a gorilla is worth one
thousand words. PLoS One. 2021;16(9):e0257508. doi:10.1371/journal.pone.0257508.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/837801/psn-pdf
August 10, 2022 - Decreasing misdiagnoses of urinary tract infections in a
pediatric emergency department.
August 10, 2022
Ostrow O, Prodanuk M, Foong Y, et al. Decreasing misdiagnoses of urinary tract infections in a pediatric
emergency department. Pediatrics. 2022;150(1):e2021055866. doi:10.1542/peds.2021-055866.
https://psnet.ah…
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psnet.ahrq.gov/node/866728/psn-pdf
September 18, 2024 - ROI for a fall prevention intervention: invest a little, save a
lot.
September 18, 2024
Cooper AS. ROI for a fall prevention intervention: invest a little, save a lot. Nurs Adm Q. 2024;48(3):248-
252. doi:10.1097/naq.0000000000000647.
https://psnet.ahrq.gov/issue/roi-fall-prevention-intervention-invest-little-save…
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psnet.ahrq.gov/node/866746/psn-pdf
September 18, 2024 - Looking beyond LinkedIn: the case for excellence and
academic rigor in quality and safety programs.
September 18, 2024
Bearman G, Nori P. Looking beyond LinkedIn: the case for excellence and academic rigor in quality and
safety programs. Am J Med. 2024;137(8):694-697. doi:10.1016/j.amjmed.2024.04.018.
https://psne…
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psnet.ahrq.gov/node/866311/psn-pdf
January 01, 2025 - Systematic review of types of safety incidents and the
processes and systems used for safety incident reporting
in care homes.
July 17, 2024
Scott J, Sykes K, Waring J, et al. Systematic review of types of safety incidents and the processes and
systems used for safety incident reporting in care homes. J Adv Nurs. …
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psnet.ahrq.gov/node/862984/psn-pdf
February 21, 2024 - Machine learning in medication prescription: a systematic
review.
February 21, 2024
Iancu A, Leb I, Prokosch H-U, et al. Machine learning in medication prescription: a systematic review. Int J
Med Inform. 2023;180:105241. doi:10.1016/j.ijmedinf.2023.105241.
https://psnet.ahrq.gov/issue/machine-learning-medication-…
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psnet.ahrq.gov/node/46577/psn-pdf
April 03, 2018 - The new diagnostic team.
April 3, 2018
Graber ML, Rusz D, Jones ML, et al. The new diagnostic team. Diagnosis (Berl). 2017;4(4):225-238.
doi:10.1515/dx-2017-0022.
https://psnet.ahrq.gov/issue/new-diagnostic-team
Teamwork has been highlighted as a key component of patient safety that also applies to improving
diag…
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psnet.ahrq.gov/node/35207/psn-pdf
December 19, 2009 - Patient safety concerns arising from test results that
return after hospital discharge.
December 19, 2009
Roy CL, Poon EG, Karson A, et al. Patient safety concerns arising from test results that return after hospital
discharge. Ann Intern Med. 2005;143(2):121-128.
https://psnet.ahrq.gov/issue/patient-safety-concer…
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psnet.ahrq.gov/node/39277/psn-pdf
August 22, 2018 - Preventing maternal death.
August 22, 2018
Preventing maternal death. Sentinel Event Alert. 2010;44(44):1-4.
https://psnet.ahrq.gov/issue/preventing-maternal-death
The Joint Commission issues Sentinel Event Alerts to highlight areas of high risk and to promote the rapid
adoption of risk reduction strategies. Adher…
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psnet.ahrq.gov/node/48180/psn-pdf
August 21, 2019 - Burnout and Resilience and Quality and Safety Programs
in Obstetrics and Gynecology.
August 21, 2019
Main EK, Fowler JM, Gabbe SG, eds. Clin Obstet Gynecol. 2019;62:vii-xii,403-626.
https://psnet.ahrq.gov/issue/burnout-and-resilience-and-quality-and-safety-programs-obstetrics-and-
gynecology
Obstetrics is a high-…
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psnet.ahrq.gov/node/44957/psn-pdf
March 09, 2016 - Government and industry fail to protect the public when
they suggest "carefully following instructions" is enough
to prevent vaccine errors.
March 9, 2016
ISMP Medication Safety Alert! Acute care edition. February 25, 2016;21(4):1-5.
https://psnet.ahrq.gov/issue/government-and-industry-fail-protect-public-when-the…
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psnet.ahrq.gov/node/60813/psn-pdf
January 01, 2021 - Medication-related interventions delivered both in
hospital and following discharge: a systematic review and
meta-analysis.
August 19, 2020
Daliri S, Boujarfi S, el Mokaddam A, et al. Medication-related interventions delivered both in hospital and
following discharge: a systematic review and meta-analysis. BMJ Qua…
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psnet.ahrq.gov/node/838080/psn-pdf
September 14, 2022 - Effect on diagnostic accuracy of cognitive reasoning
tools for the workplace setting: systematic review and
meta-analysis.
September 14, 2022
Staal J, Hooftman J, Gunput STG, et al. Effect on diagnostic accuracy of cognitive reasoning tools for the
workplace setting: systematic review and meta-analysis. BMJ Qual S…
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psnet.ahrq.gov/node/46247/psn-pdf
August 08, 2018 - Distractions in the anesthesia work environment: impact
on patient safety? Report of a meeting sponsored by the
Anesthesia Patient Safety Foundation.
August 8, 2018
van Pelt M, Weinger MB. Distractions in the Anesthesia Work Environment: Impact on Patient Safety?
Report of a Meeting Sponsored by the Anesthesia Pat…