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psnet.ahrq.gov/node/45283/psn-pdf
June 29, 2016 - Goals and Priorities for Health Care Organizations to
Improve Safety Using Health IT. Revised Report.
June 29, 2016
Graber ML, Bailey R, Johnston D. RTI International; Washington, DC: US Department of Health and
Human Services, Office of the National Coordinator for Health Information Technology; 2016.
https://psn…
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psnet.ahrq.gov/node/43197/psn-pdf
August 12, 2014 - An observational study: associations between nurse-
reported hospital characteristics and estimated 30-day
survival probabilities.
August 12, 2014
Tvedt C, Sjetne IS, Helgeland J, et al. An observational study: associations between nurse-reported
hospital characteristics and estimated 30-day survival probabilities…
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psnet.ahrq.gov/node/39895/psn-pdf
September 21, 2011 - Improving America's Hospitals: The Joint Commission's
Annual Report on Quality and Safety 2010.
September 21, 2011
Oakbrook Terrace, IL: The Joint Commission; September 2010.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety-2010
In the fifth report on t…
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psnet.ahrq.gov/node/41739/psn-pdf
November 28, 2016 - New system for patients to report medical mistakes.
November 28, 2016
Pear R.
https://psnet.ahrq.gov/issue/new-system-patients-report-medical-mistakes
The newspaper article discusses a proposed federal initiative for patients and families to report
experiences with medical errors.
https://psnet.ahrq.gov/issue/new…
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psnet.ahrq.gov/node/35275/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis
This monthly selection of medication error reports provides examples from the field of potential errors and
helpful tips on how to avoid similar mistakes.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/issue/opioids-and-falls-risk-older-adults-narrative-review
January 12, 2022 - Review
Opioids and falls risk in older adults: a narrative review.
Citation Text:
Virnes R-E, Tiihonen M, Karttunen N, et al. Opioids and falls risk in older adults: a narrative review. Drugs Aging. 2022;39(3):199-207. doi:10.1007/s40266-022-00929-y.
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psnet.ahrq.gov/issue/publics-views-medical-error-massachusetts
January 30, 2019 - Book/Report
The Public's Views on Medical Error in Massachusetts.
Citation Text:
The Public's Views on Medical Error in Massachusetts. Boston, MA: Harvard School of Public Health; December 2014.
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psnet.ahrq.gov/node/38933/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-38
This monthly selection of error reports discusses incidents involving insulin preparation, automated
medication cabinet stocking, and medication list filing.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/36257/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-7
This monthly selection of medication error reports provides examples of problems related to poorly
scanned pharmacy orders, ambiguous labeling, and abbreviation use.
https://psnet.ah…
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psnet.ahrq.gov/node/35560/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-2
This monthly selection of medication error reports provides examples of problems with neuromuscular
blocking agents, confusion with drug names, and unclear labeling practices.
https:…
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psnet.ahrq.gov/node/36840/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-11
This monthly selection of medication error reports provides examples of problems related to abbreviations,
electronic prescribing, and communication of critical lab values.
https://…
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psnet.ahrq.gov/node/36071/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-6
This monthly selection of medication error reports provides examples of nimodipine administration
mishaps, a lithium overdose, and suggested adopted drug names for review.
https://ps…
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psnet.ahrq.gov/node/37461/psn-pdf
May 11, 2014 - ISMP medication error report analysis.
May 11, 2014
Cohen MR; Smetzer JL.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-20
This monthly selection of medication error reports discusses problems related to a lack of standardization
in IV dosing and talc misadministration.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/37897/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-26
This monthly selection of medication error reports includes examples of look-alike/sound-alike medications
and a discussion of immunosuppressant dosing errors.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/42055/psn-pdf
April 24, 2013 - Report of the Mid Staffordshire NHS Foundation Trust:
Public Inquiry.
April 24, 2013
Francis R. London, UK: The Stationary Office; 2013. ISBN: 9780102981469.
https://psnet.ahrq.gov/issue/report-mid-staffordshire-nhs-foundation-trust-public-inquiry
In 2010 the United Kingdom's Secretary of State for Health a…
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psnet.ahrq.gov/node/849121/psn-pdf
May 17, 2023 - Thematic reviews of patient safety incidents as a tool for
systems thinking: a quality improvement report.
May 17, 2023
Machen S. Thematic reviews of patient safety incidents as a tool for systems thinking: a quality
improvement report. BMJ Open Qual. 2023;12(2):e002020. doi:10.1136/bmjoq-2022-002020.
https://psne…
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psnet.ahrq.gov/node/47853/psn-pdf
April 10, 2019 - Does a unit shift report "blackout" period improve patient
safety?
April 10, 2019
Olmstead J. Does a unit shift report "blackout" period improve patient safety? Nurs Manage. 2019;50(3):8-
10. doi:10.1097/01.NUMA.0000553500.85897.51.
https://psnet.ahrq.gov/issue/does-unit-shift-report-blackout-period-improve-patien…
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psnet.ahrq.gov/node/44805/psn-pdf
January 27, 2016 - NHS Safety Thermometer Reports.
January 27, 2016
Leeds, UK: Clinical Support Audit Unit, Health and Social Care Information Centre. 2012-2017.
https://psnet.ahrq.gov/issue/nhs-safety-thermometer-report-patient-harms-and-harm-free-care-november-
2014-november-2015
The NHS Safety Thermometer was a tool developed by …
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psnet.ahrq.gov/node/47535/psn-pdf
November 07, 2018 - Gosport War Memorial Hospital. The Report of the
Gosport Independent Panel.
November 7, 2018
Gosport Independent Panel. London, England: Crown Copyright; 2018. ISBN: 9781528604062.
https://psnet.ahrq.gov/issue/gosport-war-memorial-hospital-report-gosport-independent-panel
Organizational culture influences how comf…
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psnet.ahrq.gov/node/72483/psn-pdf
November 18, 2020 - ACGME Summary Report: The Pursuing Excellence
Pathway Leaders Patient Safety Collaborative.
November 18, 2020
Passiment M, Wagner R, Weiss KB for the Pursuing Excellence in Clinical Learning Environments:
Pathway Leaders Patient Safety Collaborative. Chicago, IL: Accreditation Council for Graduate Medical
Educatio…