-
psnet.ahrq.gov/node/39817/psn-pdf
March 18, 2011 - Checking it twice: an evaluation of checklists for
detecting medication errors at the bedside using a
chemotherapy model.
March 18, 2011
White RE, Trbovich PL, Easty AC, et al. Checking it twice: an evaluation of checklists for detecting
medication errors at the bedside using a chemotherapy model. Qual Saf Health …
-
psnet.ahrq.gov/node/38048/psn-pdf
October 03, 2017 - Indiana Medical Error Reporting System.
October 3, 2017
Indianapolis, IN: Indiana State Department of Health.
https://psnet.ahrq.gov/issue/indiana-medical-error-reporting-system-final-report-2015
This website shares requirement for reporting never events to the Indiana Medical Error Reporting System.
The most comm…
-
psnet.ahrq.gov/node/36367/psn-pdf
April 11, 2011 - Emergency medical services system changes reduce
pediatric epinephrine dosing errors in the prehospital
setting.
April 11, 2011
Kaji AH, Gausche-Hill M, Conrad H, et al. Emergency medical services system changes reduce pediatric
epinephrine dosing errors in the prehospital setting. Pediatrics. 2006;118(4):1493-150…
-
psnet.ahrq.gov/node/837982/psn-pdf
August 31, 2022 - Patient Safety Incident Response Framework.
August 31, 2022
London, England: NHS England; August 2022.
https://psnet.ahrq.gov/issue/patient-safety-incident-response-framework
Effective response to medical error requires a comprehensive systemic and process-focused incident
examination approach to ensure organizati…
-
psnet.ahrq.gov/node/47132/psn-pdf
June 28, 2018 - National Steering Committee for Patient Safety.
June 28, 2018
Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement.
https://psnet.ahrq.gov/issue/national-steering-committee-patient-safety
Preventable patient harm is a global public health concern. This announcement highlights a ne…
-
psnet.ahrq.gov/node/73970/psn-pdf
October 21, 2021 - The Good, The Bad, and The Ugly: Patient Experiences
with CRPs.
October 13, 2021
Collaborative for Accountability and Improvement. October 21, 2021.
https://psnet.ahrq.gov/issue/good-bad-and-ugly-patient-experiences-crps
Communication-and-resolution program (CRP) initiatives are a valuable strategy for impro…
-
psnet.ahrq.gov/node/35158/psn-pdf
January 02, 2017 - Using simulation-based training to improve patient safety:
what does it take?
January 2, 2017
Salas E, Wilson K, Burke S, et al. Using simulation-based training to improve patient safety: what does it
take? Jt Comm J Qual Patient Saf. 2005;31(7):363-71.
https://psnet.ahrq.gov/issue/using-simulation-based-training-…
-
psnet.ahrq.gov/node/44617/psn-pdf
January 22, 2016 - Pediatric prehospital medication dosing errors: a mixed-
methods study.
January 22, 2016
Hoyle JD, Sleight D, Henry R, et al. Pediatric prehospital medication dosing errors: a mixed-methods study.
Prehosp Emerg Care. 2016;20(1):117-124. doi:10.3109/10903127.2015.1061625.
https://psnet.ahrq.gov/issue/pediatric-preh…
-
psnet.ahrq.gov/node/43223/psn-pdf
April 22, 2015 - Double gloves: a randomized trial to evaluate a simple
strategy to reduce contamination in the operating room.
April 22, 2015
Birnbach DJ, Rosen LF, Fitzpatrick M, et al. Double gloves: a randomized trial to evaluate a simple strategy
to reduce contamination in the operating room. Anesth Analg. 2015;120(4):848-52.
…
-
psnet.ahrq.gov/node/38072/psn-pdf
February 15, 2011 - Detection, classification, and correction of defective
chemotherapy orders through nursing and pharmacy
oversight.
February 15, 2011
Mertens WC, Brown DE, Parisi R, et al. Detection, Classification, and Correction of Defective
Chemotherapy Orders Through Nursing and Pharmacy Oversight. J Patient Saf. 2008;4(3):195…
-
psnet.ahrq.gov/node/40527/psn-pdf
June 15, 2011 - Online medication error graphic reports: a pilot in North
Carolina nursing homes.
June 15, 2011
Greene SB, Williams CE, Pierson S, et al. Online medication error graphic reports: a pilot in North Carolina
nursing homes. J Patient Saf. 2011;7(2):92-8. doi:10.1097/PTS.0b013e31821b4eab.
https://psnet.ahrq.gov/issue/o…
-
psnet.ahrq.gov/node/44298/psn-pdf
July 08, 2015 - Preparing challenging medications for barcode scanning.
July 8, 2015
Waxlax TJ. Preparing challenging medications for barcode scanning. Am J Health Syst Pharm.
2015;72(13):1089-90. doi:10.2146/ajhp140454.
https://psnet.ahrq.gov/issue/preparing-challenging-medications-barcode-scanning
Barcode scanning can reduce me…
-
psnet.ahrq.gov/node/47994/psn-pdf
July 16, 2019 - What's in a name? Newborn naming conventions and
wrong-patient errors.
July 16, 2019
ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.
https://psnet.ahrq.gov/issue/whats-name-newborn-naming-conventions-and-wrong-patient-errors
Newborns assigned temporary names are at increased risk for patient misi…
-
psnet.ahrq.gov/node/36485/psn-pdf
June 13, 2011 - Pharmacist-supported medication review training for
general practitioners: feasibility and acceptability.
June 13, 2011
Krska J, Gill D, Hansford D. Pharmacist-supported medication review training for general practitioners:
feasibility and acceptability. Med Educ. 2006;40(12). doi:10.1111/j.1365-2929.2006.02633.x.
…
-
psnet.ahrq.gov/node/46750/psn-pdf
January 31, 2018 - Iowans' Views on Medical Errors: Iowa Patient Safety
Study.
January 31, 2018
Clive, IA: Heartland Health Research Institute; January 7, 2018.
https://psnet.ahrq.gov/issue/iowans-views-medical-errors-iowa-patient-safety-study
Patient perspectives can provide insights regarding areas in need of improvement. This sur…
-
psnet.ahrq.gov/node/44432/psn-pdf
August 19, 2015 - Validating a decision tree for serious infection: diagnostic
accuracy in acutely ill children in ambulatory care.
August 19, 2015
Verbakel JY, Lemiengre MB, De Burghgraeve T, et al. Validating a decision tree for serious infection:
diagnostic accuracy in acutely ill children in ambulatory care. BMJ Open. 2015;5(8):…
-
psnet.ahrq.gov/node/40980/psn-pdf
December 31, 2014 - Transmitting and processing electronic prescriptions:
experiences of physician practices and pharmacies.
December 31, 2014
Grossman JM, Cross DA, Boukus ER, et al. Transmitting and processing electronic prescriptions:
experiences of physician practices and pharmacies. J Am Med Inform Assoc. 2012;19(3):353-9.
doi:1…
-
psnet.ahrq.gov/node/72583/psn-pdf
December 16, 2020 - Wear face masks with no metal during MRI exams.
December 16, 2020
FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug
Administration; December 7, 2020.
https://psnet.ahrq.gov/issue/wear-face-masks-no-metal-during-mri-exams
Magnetic resonance imaging (MRI) requires patient prep…
-
psnet.ahrq.gov/node/867347/psn-pdf
December 11, 2024 - Recommendations to ensure safety of AI in real-world
clinical care.
December 11, 2024
Sittig DF, Singh H. Recommendations to ensure safety of AI in real-world clinical care. JAMA.
2025;333(6):457-458. doi:10.1001/jama.2024.24598.
https://psnet.ahrq.gov/issue/recommendations-ensure-safety-ai-real-world-clinical-car…
-
psnet.ahrq.gov/node/865721/psn-pdf
May 01, 2024 - Patient Safety Rights Charter.
May 1, 2024
Geneva, Switzerland: World Health Organization; April 2024. ISBN: 9789240093249.
https://psnet.ahrq.gov/issue/patient-safety-rights-charter
Patients have the right to expect safe, equitable, high-quality care. This 10-point charter serves to describe
the establishmen…