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psnet.ahrq.gov/node/34797/psn-pdf
October 06, 2015 - Adapting to new technologies in the operating room.
October 6, 2015
Cook RI, Woods DD. Adapting to New Technology in the Operating Room. Hum Factors. 2006;38(4):593-
613. doi:10.1518/001872096778827224.
https://psnet.ahrq.gov/issue/adapting-new-technologies-operating-room
New technology continues to offer great ad…
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psnet.ahrq.gov/node/45468/psn-pdf
October 11, 2017 - Identification and characterization of adverse drug events
in primary care.
October 11, 2017
Trinkley KE, Weed HG, Beatty SJ, et al. Identification and Characterization of Adverse Drug Events in
Primary Care. Am J Med Qual. 2017;32(5):518-525. doi:10.1177/1062860616665695.
https://psnet.ahrq.gov/issue/identificati…
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psnet.ahrq.gov/node/46977/psn-pdf
April 04, 2018 - Latex: a lingering and lurking safety risk.
April 4, 2018
Liberatore K. PA-PSRS Patient Saf Advis. 2018 March;15.
https://psnet.ahrq.gov/issue/latex-lingering-and-lurking-safety-risk
Latex products are widely available in hospitals and represent a persistent threat to patients with latex
allergies. Drawing from 61…
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psnet.ahrq.gov/node/36086/psn-pdf
June 14, 2011 - Sensemaking of patient safety risks and hazards.
June 14, 2011
Battles J, Dixon NM, Borotkanics RJ, et al. Sensemaking of patient safety risks and hazards. Health Serv
Res. 2006;41(4 Pt 2):1555-1575.
https://psnet.ahrq.gov/issue/sensemaking-patient-safety-risks-and-hazards
This commentary discusses the concept of …
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psnet.ahrq.gov/node/35127/psn-pdf
February 24, 2011 - Beyond the medical record: other modes of error
acknowledgment.
February 24, 2011
Rosenthal M, Cornett PL, Sutcliffe K, et al. Beyond the medical record: other modes of error
acknowledgment. J Gen Intern Med. 2005;20(5):404-9.
https://psnet.ahrq.gov/issue/beyond-medical-record-other-modes-error-acknowledgment
Thi…
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psnet.ahrq.gov/node/50702/psn-pdf
December 04, 2019 - Smart pumps improve medication safety but increase
alert burden in neonatal care
December 4, 2019
Melton KR, Timmons K, Walsh KE, et al. Smart pumps improve medication safety but increase alert burden
in neonatal care. BMC Medical Inform Decis Mak. 2019;19(1):213. doi:10.1186/s12911-019-0945-2.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/48123/psn-pdf
August 28, 2019 - Hidden health IT hazards: a qualitative analysis of
clinically meaningful documentation discrepancies at
transfer out of the pediatric intensive care unit.
August 28, 2019
Orenstein EW, Ferro DF, Bonafide CP, et al. JAMIA Open. 2019;2(3):392-398.
https://psnet.ahrq.gov/issue/hidden-health-it-hazards-qualitative-an…
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psnet.ahrq.gov/node/60570/psn-pdf
June 10, 2020 - Indication-specific opioid prescribing for US patients with
Medicaid or private Insurance, 2017
June 10, 2020
Mikosz CA, Zhang K, Haegerich TM, et al. Indication-specific opioid prescribing for US patients with
Medicaid or private Insurance, 2017. JAMA Netw Open. 2020;3(5).
doi:10.1001/jamanetworkopen.2020.4514.
…
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psnet.ahrq.gov/node/60012/psn-pdf
March 03, 2020 - Algorithm based smartphone apps to assess risk of skin
cancer in adults: systematic review of diagnostic
accuracy studies.
March 3, 2020
Freeman K, Dinnes J, Chuchu N, et al. Algorithm based smartphone apps to assess risk of skin cancer in
adults: systematic review of diagnostic accuracy studies. BMJ. 2020;368:m12…
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psnet.ahrq.gov/node/73197/psn-pdf
April 28, 2021 - Medical Office Survey: 2020 User Database Report.
April 28, 2021
Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety CultureTM (SOPSTM). Rockville,
MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0034.
https://psnet.ahrq.gov/issue/medical-office-survey-2020-user…
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psnet.ahrq.gov/node/50863/psn-pdf
February 05, 2020 - Patient safety in inpatient mental health settings: a
systematic review.
February 5, 2020
Thibaut BI, Dewa LH, Ramtale SC, et al. Patient safety in inpatient mental health settings: a systematic
review. BMJ Open. 2019;9(12):e030230. doi:10.1136/bmjopen-2019-030230.
https://psnet.ahrq.gov/issue/patient-safety-inpat…
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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/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/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/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…