-
psnet.ahrq.gov/node/60636/psn-pdf
July 01, 2020 - Measuring the impact of medication-related interventions
on 30-day readmission rates in a skilled nursing facility.
July 1, 2020
Amin PB, Bradford CD, Rizos AL, et al. Measuring the Impact of Medication-Related Interventions on 30-
Day Readmission Rates in a Skilled Nursing Facility. J Pharm Pract. 2020;33(3):306-3…
-
psnet.ahrq.gov/node/866637/psn-pdf
September 04, 2024 - Impact of rounding checklists on the outcomes of
patients admitted to ICUs: a systematic review and meta-
analysis.
September 4, 2024
MacKinnon KM, Seshadri S, Mailman JF, et al. Impact of rounding checklists on the outcomes of patients
admitted to ICUs: a systematic review and meta-analysis. Crit Care Explor. 202…
-
psnet.ahrq.gov/node/60898/psn-pdf
September 09, 2020 - Sequential implementation of the EQUIPPED geriatric
medication safety program as a learning health system.
September 9, 2020
Vandenberg AE, Kegler M, Hastings SN, et al. Sequential implementation of the EQUIPPED geriatric
medication safety program as a learning health system. Int J Qual Health Care. 2020;32(7):470-…
-
psnet.ahrq.gov/node/837632/psn-pdf
July 06, 2022 - Serious experience events: applying patient safety
concepts to improve patient experience.
July 6, 2022
Donnelly LF, Uhlhorn E, Bargmann-Losche J, et al. Serious experience events: applying patient safety
concepts to improve patient experience. J Patient Exp. 2022;9:237437352211026.
doi:10.1177/23743735221102670.
…
-
psnet.ahrq.gov/node/74719/psn-pdf
February 02, 2022 - Failure to rescue following emergency surgery: a FRAM
analysis of the management of the deteriorating patient.
February 2, 2022
Sujan M, Bilbro N, Ross A, et al. Failure to rescue following emergency surgery: A FRAM analysis of the
management of the deteriorating patient. Appl Ergon. 2022;98:103608. doi:10.1016/j.a…
-
psnet.ahrq.gov/node/47194/psn-pdf
August 22, 2018 - Labeling morphine milligram equivalents on opioid
packaging: a potential patient safety intervention.
August 22, 2018
Stone AB, Urman RD, Kaye AD, et al. Labeling Morphine Milligram Equivalents on Opioid Packaging: a
Potential Patient Safety Intervention. Curr Pain Headache Rep. 2018;22(7):46. doi:10.1007/s11916-01…
-
psnet.ahrq.gov/node/40743/psn-pdf
February 01, 2019 - Radiation risks of diagnostic imaging and fluoroscopy.
December 23, 2016
Sentinel Event Alert. August 24, 2011;47:1-4. (revised February 2019).
https://psnet.ahrq.gov/issue/radiation-risks-diagnostic-imaging
The Joint Commission issues Sentinel Event Alerts periodically to highlight emerging patient safety issues
…
-
psnet.ahrq.gov/node/73635/psn-pdf
August 25, 2021 - Impact of smart pump-electronic health record
interoperability on patient safety and finances at a
community hospital
August 25, 2021
Wei W, Coffey W, Adeola M, et al. Impact of smart pump-electronic health record interoperability on patient
safety and finances at a community hospital. Am J Health Syst Pharm. 2021…
-
psnet.ahrq.gov/node/853242/psn-pdf
September 06, 2023 - Protocolization of analgesia and sedation through smart
technology in intensive care: improving patient safety.
September 6, 2023
Ojeda IM, Sánchez-Cuervo M, Candela-Toha Á, et al. Protocolization of Analgesia and Sedation Through
Smart Technology in Intensive Care: Improving Patient Safety. Crit Care Nurs. 2023;43…
-
psnet.ahrq.gov/node/72790/psn-pdf
March 03, 2021 - Parent engagement in perinatal mortality reviews: an
online survey of clinicians from six high-income
countries.
March 3, 2021
Boyle FM, Horey D, Siassakos D, et al. Parent engagement in perinatal mortality reviews: an online survey
of clinicians from six high?income countries. BJOG. 2020;128(4):696-703. doi:10.11…
-
psnet.ahrq.gov/node/837796/psn-pdf
August 10, 2022 - Association between hospital acquired harm outcomes
and membership in a national patient safety collaborative.
August 10, 2022
Coffey M, Marino M, Lyren A, et al. Association between hospital acquired harm outcomes and
membership in a national patient safety collaborative. JAMA Pediatr. 2022;176(9):924-932.
doi:10…
-
psnet.ahrq.gov/node/74141/psn-pdf
December 01, 2021 - Incident reporting systems: what will it take to make them
less frustrating and achieve anything useful?
December 1, 2021
Shojania KG. Incident reporting systems: what will it take to make them less frustrating and achieve
anything useful? Jt Comm J Qual Patient Saf. 2021;47(12):755-758. doi:10.1016/j.jcjq.2021.10.…
-
psnet.ahrq.gov/node/43416/psn-pdf
August 13, 2014 - Compliance with a time-out procedure intended to
prevent wrong surgery in hospitals: results of a national
patient safety programme in the Netherlands.
August 13, 2014
van Schoten SM, Kop V, de Blok C, et al. Compliance with a time-out procedure intended to prevent wrong
surgery in hospitals: results of a national…
-
psnet.ahrq.gov/node/40376/psn-pdf
July 06, 2012 - Electronic prescribing in an ambulatory care setting: a
cluster randomized trial.
July 6, 2012
Dainty KN, Adhikari NKJ, Kiss A, et al. Electronic prescribing in an ambulatory care setting: a cluster
randomized trial. J Eval Clin Pract. 2012;18(4):761-7. doi:10.1111/j.1365-2753.2011.01657.x.
https://psnet.ahrq.gov/…
-
psnet.ahrq.gov/node/837029/psn-pdf
May 04, 2022 - Identifying patients whose symptoms are
underrecognized during treatment with breast
radiotherapy.
May 4, 2022
doi:10.1001/jamaoncol.2022.0114.
https://psnet.ahrq.gov/issue/identifying-patients-whose-symptoms-are-underrecognized-during-treatment-
breast-radiotherapy
Concordance of patient-reported symptoms and p…
-
psnet.ahrq.gov/node/36843/psn-pdf
January 05, 2017 - Improving medication reconciliation in the outpatient
setting.
January 5, 2017
Varkey P, Cunningham J, Bisping S. Improving medication reconciliation in the outpatient setting. Jt Comm
J Qual Patient Saf. 2007;33(5):286-92.
https://psnet.ahrq.gov/issue/improving-medication-reconciliation-outpatient-setting
The Jo…
-
psnet.ahrq.gov/node/44792/psn-pdf
January 13, 2016 - At the hospital, better responses to those beeping alarms.
January 13, 2016
Landro L. Wall Street Journal. January 4, 2016.
https://psnet.ahrq.gov/issue/hospital-better-responses-those-beeping-alarms
Alert fatigue is a well-known problem in hospitals. This newspaper article reports on efforts to reduce
unnecessary…
-
psnet.ahrq.gov/node/47440/psn-pdf
April 07, 2019 - Improving inpatient mental health medication safety
through the process of obtaining HIMSS Stage 7: a case
report.
April 7, 2019
Sulkers H, Tajirian T, Paterson J, et al. JAMIA Open. 2019;2:35–39.
https://psnet.ahrq.gov/issue/improving-inpatient-mental-health-medication-safety-through-process-
obtaining-himss-sta…
-
psnet.ahrq.gov/node/34666/psn-pdf
December 22, 2009 - Error reduction and performance improvement in the
emergency department through formal teamwork training:
evaluation results of the MedTeams project.
December 22, 2009
Morey JC, Simon R, Jay G, et al. Error reduction and performance improvement in the emergency
department through formal teamwork training: evaluati…
-
psnet.ahrq.gov/node/41719/psn-pdf
November 27, 2012 - A systematic review of the effectiveness, compliance, and
critical factors for implementation of safety checklists in
surgery.
November 27, 2012
Borchard A, Schwappach DLB, Barbir A, et al. A systematic review of the effectiveness, compliance, and
critical factors for implementation of safety checklists in surgery…