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psnet.ahrq.gov/node/74075/psn-pdf
November 17, 2021 - CDC guideline for opioid prescribing associated with
reduced dispensing to certain patients with chronic pain.
November 17, 2021
Townsend T, Cerdá M, Bohnert AS, et al. CDC guideline for opioid prescribing associated with reduced
dispensing to certain patients with chronic pain. Health Aff (Millwood). 2021;40(11):1…
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psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
January 01, 2019 - interested family members including
– Designated health care agent (sometimes also
called surrogate, representative
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psnet.ahrq.gov/node/33628/psn-pdf
February 01, 2006 - The first is a representative of what is an
increasingly bygone era.
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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - as well as other individuals drawn from all levels of the organization, and inclusion of a patient representative
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psnet.ahrq.gov/node/41741/psn-pdf
October 10, 2012 - Improving America's Hospitals—The Joint Commission's
Annual Report on Quality and Safety.
October 10, 2012
Oakbrook Terrace, IL: Joint Commission.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety
The Joint Commission's annual report summarizes hospital …
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psnet.ahrq.gov/node/46062/psn-pdf
December 19, 2017 - Frequency and nature of medication errors and adverse
drug events in mental health hospitals: a systematic
review.
December 19, 2017
Alshehri GH, Keers RN, Ashcroft DM. Frequency and nature of medication errors and adverse drug events
in mental health hospitals: a systematic review. Drug Saf. 2017;40(10):871-886. …
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psnet.ahrq.gov/node/34811/psn-pdf
March 28, 2005 - Medication error prevention by clinical pharmacists in two
children's hospitals.
March 28, 2005
Folli HL; Poole RL; Benitz WE; Russo JC
https://psnet.ahrq.gov/issue/medication-error-prevention-clinical-pharmacists-two-childrens-hospitals
This prospective study recorded the rate and potential for harm caused by err…
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psnet.ahrq.gov/node/44911/psn-pdf
February 17, 2016 - Improving doctor–patient communication in a digital
world.
February 17, 2016
Lakshmanan I. The Diane Rehm Show. February 9, 2016.
https://psnet.ahrq.gov/issue/improving-doctor-patient-communication-digital-world
Digital technologies represent both promise and risks for communication in health care. This radio inte…
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psnet.ahrq.gov/node/35038/psn-pdf
January 02, 2017 - Using Six Sigma to reduce medication errors in a home-
delivery pharmacy service.
January 2, 2017
Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery
pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24.
https://psnet.ahrq.gov/issue/using-six-sigma-redu…
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psnet.ahrq.gov/node/46261/psn-pdf
July 18, 2018 - Pilot Testing Fall TIPS (Tailoring Interventions for Patient
Safety): a patient-centered fall prevention toolkit.
July 18, 2018
Dykes PC, Duckworth M, Cunningham S, et al. Pilot Testing Fall TIPS (Tailoring Interventions for Patient
Safety): a Patient-Centered Fall Prevention Toolkit. Jt Comm J Qual Patient Saf. 20…
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psnet.ahrq.gov/node/35635/psn-pdf
June 24, 2010 - Patient safety problems in adolescent medical care.
June 24, 2010
Woods D, Holl JL, Klein JD, et al. Patient safety problems in adolescent medical care. J Adolesc Health.
2006;38(1):5-12.
https://psnet.ahrq.gov/issue/patient-safety-problems-adolescent-medical-care
Using data from the Colorado and Utah Medical Prac…
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psnet.ahrq.gov/node/35736/psn-pdf
May 27, 2011 - Video capture of clinical care to enhance patient safety.
May 27, 2011
Weinger MB, Gonzales DC, Slagle J, et al. Video capture of clinical care to enhance patient safety. Qual
Saf Health Care. 2004;13(2):136-44.
https://psnet.ahrq.gov/issue/video-capture-clinical-care-enhance-patient-safety
This study describes th…
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psnet.ahrq.gov/node/45934/psn-pdf
March 01, 2017 - The evolving role of medical scribe: variation and
implications for organizational effectiveness and safety.
March 1, 2017
Woodcock D, Pranaat R, McGrath K, et al. The Evolving Role of Medical Scribe: Variation and Implications
for Organizational Effectiveness and Safety. Stud Health Technol Inform. 2017;234:382-38…
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psnet.ahrq.gov/node/45716/psn-pdf
September 29, 2017 - Microanalysis of video from the operating room: an
underused approach to patient safety research.
September 29, 2017
Bezemer J, Cope A, Korkiakangas T, et al. Microanalysis of video from the operating room: an underused
approach to patient safety research. BMJ Qual Saf. 2017;26(7):583-587. doi:10.1136/bmjqs-2016-00…
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psnet.ahrq.gov/node/35227/psn-pdf
June 15, 2011 - Building a Better Delivery System: A New
Engineering/Health Care Partnership.
June 15, 2011
Reid PP, Compton WD, Grossman JH, Fanjiang G, eds. Institute of Medicine, National Academy of
Engineering, Committee on Engineering and the Health Care System. Washington, DC: National
Academies Press; 2005. ISBN-10: 030909…
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psnet.ahrq.gov/node/865532/psn-pdf
April 10, 2024 - Let us to the TWISST; Plan, Simulate, Study and Act.
April 10, 2024
Colman N, Hebbar KB. Let us to the TWISST; Plan, Simulate, Study and Act. Pediatr Qual Saf.
2023;8(4):e664. doi:10.1097/pq9.0000000000000664.
https://psnet.ahrq.gov/innovation/let-us-twisst-plan-simulate-study-and-act
In situ simulation can identi…
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psnet.ahrq.gov/node/47876/psn-pdf
March 27, 2019 - Evaluation of medication errors at the transition of care
from an ICU to non-ICU location.
March 27, 2019
Tully AP, Hammond DA, Li C, et al. Evaluation of Medication Errors at the Transition of Care From an ICU
to Non-ICU Location. Crit Care Med. 2019;47(4):543-549. doi:10.1097/CCM.0000000000003633.
https://psnet.…
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psnet.ahrq.gov/node/60814/psn-pdf
August 19, 2020 - Missed acute myocardial infarction in the emergency
department-standardizing measurement of misdiagnosis-
related harms using the SPADE method.
August 19, 2020
Sharp AL, Baecker A, Nassery N, et al. Missed acute myocardial infarction in the emergency
department–standardizing measurement of misdiagnosis-related har…
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psnet.ahrq.gov/node/764396/psn-pdf
March 02, 2022 - Family Input for Quality and Safety (FIQS): using mobile
technology for in-hospital reporting from families and
patients.
March 2, 2022
Bardach NS, Stotts JR, Fiore DM, et al. Family Input for Quality and Safety (FIQS): Using mobile
technology for in?hospital reporting from families and patients. J Hosp Med. 2022;…
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psnet.ahrq.gov/node/73130/psn-pdf
January 01, 2022 - Improving peripherally inserted central catheter
appropriateness and reducing device-related
complications: a quasiexperimental study in 52 Michigan
hospitals.
April 14, 2021
Chopra V, O'Malley M, Horowitz J, et al. Improving peripherally inserted central catheter appropriateness
and reducing device-related compl…