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psnet.ahrq.gov/node/47008/psn-pdf
October 13, 2018 - Impact of a commercial order entry system on prescribing
errors amenable to computerised decision support in the
hospital setting: a prospective pre–post study.
October 13, 2018
Pontefract SK, Hodson J, Slee A, et al. Impact of a commercial order entry system on prescribing errors
amenable to computerised decision…
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psnet.ahrq.gov/issue/ismp-medication-safety-alertr-nurse-advise-err
January 26, 2023 - Newsletter/Journal
ISMP Medication Safety Alert!® Nurse-Advise ERR.
Citation Text:
ISMP Medication Safety Alert!® Nurse-Advise ERR. Plymouth Meeting, PA: Institute for Safe Medication Practices.
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psnet.ahrq.gov/node/41775/psn-pdf
December 18, 2014 - Measuring adverse events and levels of harm in pediatric
inpatients with the Global Trigger Tool.
December 18, 2014
Kirkendall E, Kloppenborg E, Papp J, et al. Measuring adverse events and levels of harm in pediatric
inpatients with the Global Trigger Tool. Pediatrics. 2012;130(5):e1206-14. doi:10.1542/peds.2012-01…
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psnet.ahrq.gov/node/36364/psn-pdf
February 14, 2017 - National surveillance of emergency department visits for
outpatient adverse drug events.
February 14, 2017
Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency department visits for
outpatient adverse drug events. JAMA. 2006;296(15):1858-66.
https://psnet.ahrq.gov/issue/national-surveil…
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psnet.ahrq.gov/node/45509/psn-pdf
September 28, 2016 - Computerized triggers of big data to detect delays in
follow-up of chest imaging results.
September 28, 2016
Murphy DR, Meyer AND, Bhise V, et al. Computerized Triggers of Big Data to Detect Delays in Follow-up
of Chest Imaging Results. Chest. 2016;150(3):613-20. doi:10.1016/j.chest.2016.05.001.
https://psnet.ahrq…
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psnet.ahrq.gov/node/45471/psn-pdf
September 21, 2016 - Vital signs: epidemiology of sepsis: prevalence of health
care factors and opportunities for prevention.
September 21, 2016
Novosad SA, Sapiano MRP, Grigg C, et al. Vital Signs: Epidemiology of Sepsis: Prevalence of Health Care
Factors and Opportunities for Prevention. MMWR Morb Mortal Wkly Rep. 2016;65(33):864-869…
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psnet.ahrq.gov/node/37945/psn-pdf
July 26, 2010 - A survey of hospital quality improvement activities.
July 26, 2010
Cohen AB, Restuccia JD, Shwartz M, et al. A survey of hospital quality improvement activities. Med Care
Res Rev. 2008;65(5):571-95. doi:10.1177/1077558708318285.
https://psnet.ahrq.gov/issue/survey-hospital-quality-improvement-activities
The Instit…
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psnet.ahrq.gov/node/49851/psn-pdf
January 01, 2019 - One Bronchoscopy, Two Errors
January 1, 2019
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
The Case
A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic
respiratory failure…
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psnet.ahrq.gov/node/44031/psn-pdf
November 03, 2015 - Diagnostic concordance among pathologists interpreting
breast biopsy specimens.
November 3, 2015
Elmore JG, Longton GM, Carney PA, et al. Diagnostic concordance among pathologists interpreting breast
biopsy specimens. JAMA. 2015;313(11):1122-1132. doi:10.1001/jama.2015.1405.
https://psnet.ahrq.gov/issue/diagnostic…
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psnet.ahrq.gov/node/41455/psn-pdf
June 13, 2012 - Medication errors during medical emergencies in a large,
tertiary care, academic medical center.
June 13, 2012
Gokhman R, Seybert AL, Phrampus P, et al. Medication errors during medical emergencies in a large,
tertiary care, academic medical center. Resuscitation. 2012;83(4):482-7.
doi:10.1016/j.resuscitation.2011…
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psnet.ahrq.gov/node/39139/psn-pdf
June 02, 2010 - Assessing resident safety culture in nursing homes:
using the nursing home survey on resident safety.
June 2, 2010
Castle NG, Wagner LM, Perera S, et al. Assessing Resident Safety Culture in Nursing Homes. J Patient
Saf. 2010;64(2):59-67. doi:10.1097/pts.0b013e3181bc05fc.
https://psnet.ahrq.gov/issue/assessing-res…
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psnet.ahrq.gov/node/46404/psn-pdf
December 07, 2017 - Preventable and mitigable adverse events in cancer care:
measuring risk and harm across the continuum.
December 7, 2017
Lipitz-Snyderman A, Pfister D, Classen D, et al. Preventable and mitigable adverse events in cancer care:
measuring risk and harm across the continuum. Cancer. 2017;123(23):4728-4736. doi:10.1002/…
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psnet.ahrq.gov/node/42895/psn-pdf
December 18, 2014 - National trends in patient safety for four common
conditions, 2005–2011.
December 18, 2014
Wang Y, Eldridge N, Metersky M, et al. National trends in patient safety for four common conditions, 2005-
2011. N Engl J Med. 2014;370(4):341-51. doi:10.1056/NEJMsa1300991.
https://psnet.ahrq.gov/issue/national-trends-patie…
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psnet.ahrq.gov/node/45097/psn-pdf
May 09, 2017 - Changes in prescription and over-the-counter medication
and dietary supplement use among older adults in the
United States, 2005 vs 2011.
May 9, 2017
Qato DM, Wilder J, Schumm P, et al. Changes in Prescription and Over-the-Counter Medication and
Dietary Supplement Use Among Older Adults in the United States, 2005 …
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psnet.ahrq.gov/node/44112/psn-pdf
November 03, 2015 - Unexpected death within 72 hours of emergency
department visit: were those deaths preventable?
November 3, 2015
Goulet H, Guerand V, Bloom B, et al. Unexpected death within 72 hours of emergency department visit:
were those deaths preventable? Crit Care. 2015;19(1):154. doi:10.1186/s13054-015-0877-x.
https://psnet…
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psnet.ahrq.gov/node/39662/psn-pdf
April 30, 2014 - Patient record review of the incidence, consequences,
and causes of diagnostic adverse events.
April 30, 2014
Zwaan L, de Bruijne M, Wagner C, et al. Patient record review of the incidence, consequences, and causes
of diagnostic adverse events. Arch Intern Med. 2010;170(12):1015-21.
doi:10.1001/archinternmed.2010.…
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psnet.ahrq.gov/issue/using-preprinted-medication-order-forms-improve-safety-investigational-drug-use
April 24, 2024 - Commentary
Using preprinted medication order forms to improve the safety of investigational drug use.
Citation Text:
Tamer H, Shehab N. Using preprinted medication order forms to improve the safety of investigational drug use. Am J Health Syst Pharm. 2006;63(11):1022, 1025-1026, 1028. …
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psnet.ahrq.gov/node/43115/psn-pdf
December 18, 2014 - Multistate point-prevalence survey of health care-
associated infections.
December 18, 2014
Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated
infections. N Engl J Med. 2014;370(13):1198-208. doi:10.1056/NEJMoa1306801.
https://psnet.ahrq.gov/issue/multistate-point…
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psnet.ahrq.gov/node/38805/psn-pdf
April 04, 2011 - Disclosing medical errors to patients: it's not what you
say, it's what they hear.
April 4, 2011
Wu AW, Huang I-C, Stokes S, et al. Disclosing medical errors to patients: it's not what you say, it's what
they hear. J Gen Intern Med. 2009;24(9):1012-7. doi:10.1007/s11606-009-1044-3.
https://psnet.ahrq.gov/issue/dis…
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psnet.ahrq.gov/node/40073/psn-pdf
July 01, 2011 - Residents' perspectives on ACGME regulation of
supervision and duty hours—a national survey.
December 8, 2010
Drolet BC, Spalluto LB, Fischer SA. Residents' perspectives on ACGME regulation of supervision and duty
hours--a national survey. N Engl J Med. 2010;363(23):e34. doi:10.1056/NEJMp1011413.
https://psnet.ahr…