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psnet.ahrq.gov/issue/lack-standard-dosing-methods-contributes-iv-errors
December 07, 2022 - Newspaper/Magazine Article
Lack of standard dosing methods contributes to IV errors.
Citation Text:
Lack of standard dosing methods contributes to IV errors. ISMP Medication Safety Alert! Acute care edition. August 23, 2007,
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psnet.ahrq.gov/issue/malpractice-risks-communication-failures-2015-annual-benchmarking-report
July 18, 2018 - Book/Report
Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report.
Citation Text:
Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. Cambridge, MA: CRICO Strategies; 2016.
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psnet.ahrq.gov/issue/cultural-issues-related-allegations-bullying-and-harassment-nhs-highland-independent-review
July 29, 2015 - Government Resource
Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report.
Citation Text:
Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report. Sturrock J. Edinburgh, Scotland: …
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psnet.ahrq.gov/issue/proceedings-summit-preventing-patient-harm-and-death-iv-medication-errors
June 16, 2019 - Meeting/Conference Proceedings
Proceedings of a summit on preventing patient harm and death from IV medication errors.
Citation Text:
Proceedings of a summit on preventing patient harm and death from i.v. medication errors. doi:10.2146/ajhp080406.
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DO…
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psnet.ahrq.gov/node/44961/psn-pdf
May 09, 2017 - Parent-reported errors and adverse events in hospitalized
children.
May 9, 2017
Khan A, Furtak SL, Melvin P, et al. Parent-reported errors and adverse events in hospitalized children.
JAMA Pediatr. 2016;170(4):e154608. doi:10.1001/jamapediatrics.2015.4608.
https://psnet.ahrq.gov/issue/parent-reported-errors-and-ad…
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psnet.ahrq.gov/node/43566/psn-pdf
December 19, 2014 - Bedside shift reports: what does the evidence say?
December 19, 2014
Gregory S, Tan D, Tilrico M, et al. Bedside shift reports: what does the evidence say? J Nurs Adm.
2014;44(10):541-5. doi:10.1097/NNA.0000000000000115.
https://psnet.ahrq.gov/issue/bedside-shift-reports-what-does-evidence-say
Bedside shift report…
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psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
March 01, 2018 - saw huge variation in nurses' ratings of their practice environment, with around 40% of all nurses reporting
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psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
March 01, 2018 - saw huge variation in nurses' ratings of their practice environment, with around 40% of all nurses reporting
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psnet.ahrq.gov/issue/flow-information-contributing-medication-incidents-home-care-analysis-considering-incident
May 01, 2024 - Study
Flow of information contributing to medication incidents in home care- an analysis considering incident reporters' perspectives.
Citation Text:
Vellonen M, Härkänen M, Välimäki T. Flow of information contributing to medication incidents in home care— an analysis considering inciden…
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psnet.ahrq.gov/issue/2022-updated-results-ahrq-surveys-patient-safety-culture-sops-diagnostic-safety-supplemental
April 06, 2022 - Book/Report
2022 Updated Results for the AHRQ Surveys on Patient Safety Culture (SOPS) Diagnostic Safety Supplemental Items.
Citation Text:
2022 Updated Results for the AHRQ Surveys on Patient Safety Culture (SOPS) Diagnostic Safety Supplemental Items. Famolaro T, Hare R, Tapia A, et al.…
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psnet.ahrq.gov/issue/learning-bristol-report-public-inquiry-childrens-heart-surgery-bristol-royal-infirmary-1984
October 20, 2021 - Book/Report
Classic
Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984--1995.
Citation Text:
Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Brist…
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psnet.ahrq.gov/node/867638/psn-pdf
February 26, 2025 - Artificial intelligence related safety issues associated with
FDA medical device reports.
February 26, 2025
Handley JL, Krevat SA, Fong A, et al. Artificial intelligence related safety issues associated with FDA
medical device reports. NPJ Digit Med. 2024;7(1):351. doi:10.1038/s41746-024-01357-5.
https://psnet.ahr…
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psnet.ahrq.gov/node/50775/psn-pdf
January 01, 2021 - Content analysis of patient safety incident reports for
older adult patient transfers, handovers, and discharges:
do they serve organizations, staff, or patients?
January 8, 2020
Scott J, Dawson P, Heavey E, et al. Content analysis of patient safety incident reports for older adult
patient transfers, handovers, an…
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psnet.ahrq.gov/node/39256/psn-pdf
November 14, 2011 - Improving America's Hospitals: The Joint Commission's
Annual Report on Quality and Safety 2009.
November 14, 2011
Oakbrook Terrace, IL: The Joint Commission; January 2010.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety-2009
America's hospitals continu…
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psnet.ahrq.gov/node/45416/psn-pdf
August 24, 2016 - A framework to assess patient-reported adverse
outcomes arising during hospitalization.
August 24, 2016
Okoniewska B, Santana MJ, Holroyd-Leduc J, et al. A framework to assess patient-reported adverse
outcomes arising during hospitalization. BMC Health Serv Res. 2016;16(a):357. doi:10.1186/s12913-016-
1526-z.
htt…
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psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-safety-2010
November 23, 2016 - Book/Report
Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2010.
Citation Text:
Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2010. Oakbrook Terrace, IL: The Joint Commission; September 2010.
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psnet.ahrq.gov/issue/assessment-ahrq-patient-safety-initiative-moving-research-practice-evaluation-report-ii-2003
May 21, 2014 - Book/Report
Assessment of the AHRQ Patient Safety Initiative: Moving from Research to Practice Evaluation Report II (2003–2004).
Citation Text:
Assessment of the AHRQ Patient Safety Initiative: Moving from Research to Practice Evaluation Report II (2003–2004). Farley D, Morton SC, Damber…
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psnet.ahrq.gov/issue/nursing-home-survey-patient-safety-culture
November 23, 2016 - Measurement Tool/Indicator
Nursing Home Survey on Patient Safety Culture.
Citation Text:
Nursing Home Survey on Patient Safety Culture. Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
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psnet.ahrq.gov/node/34662/psn-pdf
December 24, 2008 - User's manual for the IOM's 'Quality Chasm' report.
December 24, 2008
Berwick DM. A user's manual for the IOM's 'Quality Chasm' report. Health Aff (Millwood). 2002;21(3):80-90.
https://psnet.ahrq.gov/issue/users-manual-ioms-quality-chasm-report
Fifteen months after releasing its report on patient safety (To Err Is …
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psnet.ahrq.gov/node/857461/psn-pdf
December 06, 2023 - 'Nobody cared': Women who have reported mistreatment
while giving birth say CDC report validates their trauma.
Advocates call for systemic change in treatment of
pregnant people.
December 6, 2023
Dwyer D, See P. ABC News. November 28, 2023.
https://psnet.ahrq.gov/issue/nobody-cared-women-who-have-reported-mistrea…