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psnet.ahrq.gov/node/44818/psn-pdf
February 24, 2018 - Economic evaluation of interventions for prevention of
hospital acquired infections: a systematic review.
February 24, 2018
Arefian H, Vogel M, Kwetkat A, et al. Economic Evaluation of Interventions for Prevention of Hospital
Acquired Infections: A Systematic Review. PLoS One. 2016;11(1):e0146381.
doi:10.1371/jour…
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psnet.ahrq.gov/node/859344/psn-pdf
December 20, 2023 - Nurses' perspectives on medication errors and prevention
strategies in residential aged care facilities through a
national survey.
December 20, 2023
Kuppadakkath SC, Bhowmik J, Olasoji M, et al. Nurses' perspectives on medication errors and prevention
strategies in residential aged care facilities through a nation…
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psnet.ahrq.gov/node/73614/psn-pdf
August 18, 2021 - Application of human factors methods to ensure
appropriate infant identification and abduction prevention
within the hospital setting.
August 18, 2021
Webster KLW, Stikes R, Bunnell L, et al. Application of human factors methods to ensure appropriate infant
identification and abduction prevention within the hospit…
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psnet.ahrq.gov/node/45482/psn-pdf
September 14, 2016 - 'America's other drug problem': copious prescriptions for
hospitalized elderly.
September 14, 2016
Gorman A. Kaiser Health News. August 30, 2016.
https://psnet.ahrq.gov/issue/americas-other-drug-problem-copious-prescriptions-hospitalized-elderly
Older patients are particularly vulnerable to medication errors, as t…
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psnet.ahrq.gov/node/866070/psn-pdf
June 05, 2024 - Large language models for preventing medication
direction errors in online pharmacies.
June 5, 2024
Pais C, Liu J, Voigt R, et al. Large language models for preventing medication direction errors in online
pharmacies. Nat Med. 2024;30(6):1574-1582. doi:10.1038/s41591-024-02933-8.
https://psnet.ahrq.gov/issue/large…
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psnet.ahrq.gov/node/40172/psn-pdf
January 26, 2011 - Risk of adverse drug events in neonates treated with
opioids and the effect of a bar-code–assisted medication
administration system.
January 26, 2011
Morriss FH, Abramowitz PW, Nelson S, et al. Risk of adverse drug events in neonates treated with opioids
and the effect of a bar-code-assisted medication administrat…
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psnet.ahrq.gov/node/73616/psn-pdf
August 18, 2021 - Do Black and White Patients Experience Similar Rates of
Adverse Safety Events at the Same Hospital?
August 18, 2021
Gangopadhyaya A. Washington DC; Urban Institute: July 2021.
https://psnet.ahrq.gov/issue/do-black-and-white-patients-experience-similar-rates-adverse-safety-events-
same-hospital
Racial inequities h…
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psnet.ahrq.gov/node/44844/psn-pdf
March 02, 2016 - From To Err Is Human to Improving Diagnosis in Health
Care: the risk management perspective.
March 2, 2016
Bunting RF, Groszkruger DP. From To Err Is Human to Improving Diagnosis in Health Care: The risk
management perspective. J Healthc Risk Manag. 2016;35(3):10-23. doi:10.1002/jhrm.21205.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/46133/psn-pdf
May 24, 2017 - Implementing smart infusion pumps with dose-error
reduction software: real-world experiences.
May 24, 2017
Heron C. Implementing smart infusion pumps with dose-error reduction software: real-world experiences.
Br J Nurs. 2017;26(8):S13-S16. doi:10.12968/bjon.2017.26.8.S13.
https://psnet.ahrq.gov/issue/implementing…
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psnet.ahrq.gov/node/44162/psn-pdf
May 27, 2015 - Computerised clinical decision support systems to
improve medication safety in long-term care homes: a
systematic review.
May 27, 2015
Marasinghe KM. Computerised clinical decision support systems to improve medication safety in long-term
care homes: a systematic review. BMJ Open. 2015;5(5):e006539. doi:10.1136/bm…
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psnet.ahrq.gov/node/45192/psn-pdf
December 04, 2016 - Evidence summary and recommendations for improved
communication during care transitions.
December 4, 2016
Jackson PD, Biggins MS, Cowan L, et al. Evidence Summary and Recommendations for Improved
Communication during Care Transitions. Rehabil Nurs. 2016;41(3):135-48. doi:10.1002/rnj.230.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/46566/psn-pdf
June 25, 2018 - A systematic review of interventions to follow-up test
results pending at discharge.
June 25, 2018
Darragh PJ, Bodley T, Orchanian-Cheff A, et al. A Systematic Review of Interventions to Follow-Up Test
Results Pending at Discharge. J Gen Intern Med. 2018;33(5):750-758. doi:10.1007/s11606-017-4290-9.
https://psnet.…
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psnet.ahrq.gov/node/43799/psn-pdf
January 07, 2015 - Omission of high-alert medications: a hidden danger.
January 7, 2015
Grissinger M, Alghamdi D. PA-PSRS Patient Saf Advis. December 2014;11:149-155.
https://psnet.ahrq.gov/issue/omission-high-alert-medications-hidden-danger
Analyzing incidents reported over a 4-month period, this article reveals that 21% of 2700 med…
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psnet.ahrq.gov/node/47607/psn-pdf
February 13, 2019 - Infection prevention in long-term care: re-evaluating the
system using a human factors engineering approach.
February 13, 2019
Katz MJ, Gurses AP. Infection prevention in long-term care: re-evaluating the system using a human
factors engineering approach. Infect Control Hosp Epidemiol. 2019;40(1):95-99. doi:10.1017…
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psnet.ahrq.gov/node/45699/psn-pdf
December 21, 2016 - Towards a new paradigm in laboratory medicine: the five
rights.
December 21, 2016
Plebani M. Towards a new paradigm in laboratory medicine: the five rights. Clin Chem Lab Med.
2016;54(12):1881-1891. doi:10.1515/cclm-2016-0848.
https://psnet.ahrq.gov/issue/towards-new-paradigm-laboratory-medicine-five-rights
Error…
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psnet.ahrq.gov/node/46728/psn-pdf
March 27, 2018 - Near-miss event analysis enhances the barcode
medication administration process.
March 27, 2018
Magee MC; Miller K; Patzek D; Madera C; Michalek C; Shetterly M.
https://psnet.ahrq.gov/issue/near-miss-event-analysis-enhances-barcode-medication-administration-
process
Near misses provide unique opportunities to ide…
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psnet.ahrq.gov/node/50937/psn-pdf
February 26, 2020 - Emergency intubation of children outside of the operating
room.
February 26, 2020
Long E, Barrett MJ, Peters C, et al. Emergency intubation of children outside of the operating room.
Paediatr Anaesth. 2020;30(3):319-330. doi:10.1111/pan.13784.
https://psnet.ahrq.gov/issue/emergency-intubation-children-outside-oper…
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psnet.ahrq.gov/node/850354/psn-pdf
June 14, 2023 - The effects of electronic nursing handover on patient
safety in the general (non-COVID-19) and COVID-19
intensive care units: a quasi-experimental study.
June 14, 2023
Tataei A, Rahimi B, Afshar HL, et al. The effects of electronic nursing handover on patient safety in the
general (non-COVID-19) and COVID-19 inten…
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psnet.ahrq.gov/node/854381/psn-pdf
October 11, 2023 - Addressing bias in acute postoperative pain
management.
October 11, 2023
Harbell MW, Maloney J, Anderson MA, et al. Addressing bias in acute postoperative pain management.
Curr Pain Headache Rep. 2023;27(9):407-415. doi:10.1007/s11916-023-01135-0.
https://psnet.ahrq.gov/issue/addressing-bias-acute-postoperative-pa…
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psnet.ahrq.gov/node/60327/psn-pdf
May 13, 2020 - Recommendations of individualized medical treatment
and common adverse events management for lung cancer
patients during the outbreak of COVID-19 epidemic.
May 13, 2020
Zhao Z, Bai H, Duan J, et al. Recommendations of individualized medical treatment and common adverse
events management for lung cancer patients du…