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psnet.ahrq.gov/node/44428/psn-pdf
November 20, 2015 - Test result communication in primary care: a survey of
current practice.
November 20, 2015
Litchfield I, Bentham L, Lilford RJ, et al. Test result communication in primary care: a survey of current
practice. BMJ Qual Saf. 2015;24(11):691-9. doi:10.1136/bmjqs-2014-003712.
https://psnet.ahrq.gov/issue/test-result-co…
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psnet.ahrq.gov/node/42608/psn-pdf
January 09, 2014 - Antiretroviral medication prescribing errors are common
with hospitalization of HIV-infected patients.
January 9, 2014
Commers T, Swindells S, Sayles H, et al. Antiretroviral medication prescribing errors are common with
hospitalization of HIV-infected patients. J Antimicrob Chemother. 2014;69(1):262-7. doi:10.1093…
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psnet.ahrq.gov/node/72499/psn-pdf
November 25, 2020 - Transformational improvement in quality care and health
systems: the next decade.
November 25, 2020
Braithwaite J, Vincent CA, Garcia-Elorrio E, et al. Transformational improvement in quality care and health
systems: the next decade. BMC Med. 2020;18(1):340. doi:10.1186/s12916-020-01739-y.
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psnet.ahrq.gov/node/73100/psn-pdf
March 31, 2021 - Public comment period extended for strategies to
improve patient safety: Draft Report to Congress for
Public Comment and Review by the National Academy of
Medicine.
March 31, 2021
Fed Register. 2021;86(51):14752-14753.
https://psnet.ahrq.gov/issue/public-comment-period-extended-strategies-improve-patient-safety-d…
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psnet.ahrq.gov/node/50921/psn-pdf
February 19, 2020 - How chaos at chain pharmacies is putting patients at risk.
February 19, 2020
Gabler E. New York Times. January 31, 2020.
https://psnet.ahrq.gov/issue/how-chaos-chain-pharmacies-putting-patients-risk
Pharmacists are instrumental to safe medication use in the ambulatory setting. This news story discusses
f…
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psnet.ahrq.gov/node/46298/psn-pdf
October 18, 2017 - CVS taps a design legend to reinvent the prescription
label. Next stop: the pharmacy.
October 18, 2017
Kuang C. Fast Company. October 4, 2017.
https://psnet.ahrq.gov/issue/cvs-taps-design-legend-reinvent-prescription-label-next-stop-pharmacy
Complicated systems often require more than one change to improve their s…
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psnet.ahrq.gov/node/46968/psn-pdf
April 18, 2018 - Attitudes and practices related to clinical alarms: a follow-
up survey.
April 18, 2018
Ruppel H, Funk M, Clark T, et al. Attitudes and Practices Related to Clinical Alarms: A Follow-up Survey.
Am J Crit Care. 2018;27(2):114-123. doi:10.4037/ajcc2018185.
https://psnet.ahrq.gov/issue/attitudes-and-practices-related…
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psnet.ahrq.gov/node/45948/psn-pdf
January 01, 2021 - Preoperative site marking: are we adhering to good
surgical practice?
July 26, 2017
Bathla S, Chadwick M, Nevins EJ, et al. Preoperative Site Marking. J Patient Saf. 2021;17(6):e503-e508.
doi:10.1097/pts.0000000000000398.
https://psnet.ahrq.gov/issue/preoperative-site-marking-are-we-adhering-good-surgical-practice…
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psnet.ahrq.gov/node/74207/psn-pdf
December 22, 2021 - The impact of health information management
professionals on patient safety: a systematic review.
December 22, 2021
Kemp T, Butler?Henderson K, Allen P, et al. The impact of health information management professionals
on patient safety: a systematic review. Health Info Libr J. 2021;38(4):248-258. doi:10.1111/hir.12…
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psnet.ahrq.gov/node/854382/psn-pdf
October 11, 2023 - Battling alarm fatigue in the pediatric intensive care unit.
October 11, 2023
Herrera H, Wood D. Battling alarm fatigue in the pediatric intensive care unit. Crit Care Nurs Clin North Am.
2023;35(3):347-355. doi:10.1016/j.cnc.2023.05.003.
https://psnet.ahrq.gov/issue/battling-alarm-fatigue-pediatric-intensive-care-…
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psnet.ahrq.gov/node/40690/psn-pdf
August 17, 2011 - Designing a safer process to prevent retained surgical
sponges: a healthcare failure mode and effect analysis.
August 17, 2011
Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare
failure mode and effect analysis. AORN J. 2011;94(2):132-41. doi:10.1016/j.aorn.2010.09.…
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psnet.ahrq.gov/node/45423/psn-pdf
September 27, 2016 - Lost in translation: impact of language barriers on
children's healthcare.
September 27, 2016
Goenka PK. Lost in translation: impact of language barriers on children's healthcare. Curr Opin Pediatr.
2016;28(5):659-666. doi:10.1097/MOP.0000000000000404.
https://psnet.ahrq.gov/issue/lost-translation-impact-language-…
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psnet.ahrq.gov/node/46973/psn-pdf
June 25, 2018 - Balancing innovation and safety when integrating digital
tools into health care.
June 25, 2018
Auerbach AD, Neinstein A, Khanna R. Balancing Innovation and Safety When Integrating Digital Tools Into
Health Care. Ann Intern Med. 2018;168(10):733-734. doi:10.7326/M17-3108.
https://psnet.ahrq.gov/issue/balancing-inno…
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psnet.ahrq.gov/node/44365/psn-pdf
November 20, 2015 - A prospective study of suicide screening tools and their
association with near-term adverse events in the ED.
November 20, 2015
Chang BP, Tan TM. Suicide screening tools and their association with near-term adverse events in the ED.
Am J Emerg Med. 2015;33(11):1680-1683. doi:10.1016/j.ajem.2015.08.013.
https://psn…
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psnet.ahrq.gov/node/43842/psn-pdf
January 28, 2015 - Should health care providers be forced to apologise after
things go wrong?
January 28, 2015
McLennan S, Walker S, Rich LE. Should health care providers be forced to apologise after things go
wrong? J Bioeth Inq. 2014;11(4):431-5. doi:10.1007/s11673-014-9571-y.
https://psnet.ahrq.gov/issue/should-health-care-provid…
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psnet.ahrq.gov/node/47341/psn-pdf
August 29, 2018 - AORN Position Statement on Criminalization of Human
Errors in the Perioperative Setting.
August 29, 2018
AORN Position Statement on Criminalization of Human Errors in the Perioperative Setting. AORN J.
2018;108(1):64-65. doi:10.1002/aorn.12292.
https://psnet.ahrq.gov/issue/aorn-position-statement-criminalization-h…
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psnet.ahrq.gov/node/43030/psn-pdf
March 26, 2014 - Recommendations for practitioners and manufacturers to
address system-based causes of vaccine errors.
March 26, 2014
ISMP Medication Safety Alert! Acute care edition. March 13, 2014;19:1-2,4-5.
https://psnet.ahrq.gov/issue/recommendations-practitioners-and-manufacturers-address-system-based-
causes-vaccine-…
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psnet.ahrq.gov/node/43048/psn-pdf
April 02, 2014 - Building a Culture of Candour: a Review of the Threshold
for the Duty of Candour and of the Incentives for Care
Organisations to Be Candid.
April 2, 2014
Dalton D, Williams N. London, UK: The Royal College of Surgeons of England; March 2014.
https://psnet.ahrq.gov/issue/building-culture-candour-review-thresh…
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psnet.ahrq.gov/node/39731/psn-pdf
August 04, 2010 - Comparing errors in ED computer-assisted vs
conventional pediatric drug dosing and administration.
August 4, 2010
Yamamoto LG, Kanemori J. Comparing errors in ED computer-assisted vs conventional pediatric drug
dosing and administration. Am J Emerg Med. 2010;28(5):588-92. doi:10.1016/j.ajem.2009.02.009.
https://ps…
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psnet.ahrq.gov/node/74015/psn-pdf
October 27, 2021 - Safer Services: A Toolkit for Specialist Mental Health
Services and Primary Care.
October 27, 2021
National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: University of
Manchester; May 31, 2021
https://psnet.ahrq.gov/issue/safer-services-toolkit-specialist-mental-health-services-and…