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psnet.ahrq.gov/node/866589/psn-pdf
August 28, 2024 - Developing a process to measure actual harm from
medication errors in paediatric inpatients: from design to
implementation.
August 28, 2024
Mumford V, Raban MZ, Li L, et al. Developing a process to measure actual harm from medication errors in
paediatric inpatients: from design to implementation. Br J Clin Pharmac…
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psnet.ahrq.gov/node/73317/psn-pdf
May 26, 2021 - Clinical and economic impacts of explicit tools detecting
prescribing errors: a systematic review.
May 26, 2021
Farhat A, Al?Hajje A, Csajka C, et al. Clinical and economic impacts of explicit tools detecting prescribing
errors: A systematic review. J Clin Pharm Ther. 2021;46(4):877-886. doi:10.1111/jcpt.13408.
ht…
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psnet.ahrq.gov/node/35309/psn-pdf
January 02, 2017 - Advising patients about patient safety: current initiatives
risk shifting responsibility.
January 2, 2017
Entwistle V, Mello MM, Brennan TA. Advising Patients About Patient Safety: Current Initiatives Risk
Shifting Responsibility. Jt Comm J Qual Patient Saf. 2005;31(9):483-494. doi:10.1016/s1553-
7250(05)31063-4.
…
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psnet.ahrq.gov/node/862131/psn-pdf
February 07, 2024 - Prospective study of the multisite spread of a medication
safety intervention: factors common to hospitals with
improved outcomes.
February 7, 2024
Kaplan HC, Goldstein SL, Rubinson C, et al. Prospective study of the multisite spread of a medication
safety intervention: factors common to hospitals with improved ou…
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psnet.ahrq.gov/node/846757/psn-pdf
March 29, 2023 - Managing interruptions to improve diagnostic decision-
making: strategies and recommended research agenda.
March 29, 2023
Sloane JF, Donkin C, Newell BR, et al. Managing interruptions to improve diagnostic decision-making:
strategies and recommended research agenda. J Gen Intern Med. 2023;38(6):1526-1531.
doi:10.1…
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psnet.ahrq.gov/node/72633/psn-pdf
January 13, 2021 - Speaking up about patient-perceived serious visit note
errors: patient and family experiences and
recommendations.
January 13, 2021
Lam BD, Bourgeois FC, Dong ZJ, et al. Speaking up about patient-perceived serious visit note errors:
Patient and family experiences and recommendations. J Am Med Inform Assoc. 2021;28…
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psnet.ahrq.gov/node/61091/psn-pdf
November 04, 2020 - Prioritising recommendations following analyses of
adverse events in healthcare: a systematic review.
November 4, 2020
Bos K, van der Laan MJ, Dongelmans DA. Prioritising recommendations following analyses of adverse
events in healthcare: a systematic review. BMJ Open Qual. 2020;9(4):e000843. doi:10.1136/bmjoq-2019…
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psnet.ahrq.gov/node/36294/psn-pdf
July 14, 2010 - Care management implementation and patient safety.
July 14, 2010
Alexander JA; Weiner BJ; Baker LC; et al. J Patient Saf. 2006;2(2):83-96.
https://psnet.ahrq.gov/issue/care-management-implementation-and-patient-safety
The Institute of Medicine's Crossing the Quality Chasm report endorsed care management, defined as…
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psnet.ahrq.gov/node/864848/psn-pdf
March 20, 2024 - An mHealth design to promote medication safety in
children with medical complexity.
March 20, 2024
Jolliff A, Coller RJ, Kearney H, et al. An mHealth design to promote medication safety in children with
medical complexity. Appl Clin Inform. 2024;15(1):45-54. doi:10.1055/a-2214-8000.
https://psnet.ahrq.gov/issue/mh…
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psnet.ahrq.gov/issue/emergency-nursing-and-medical-error-survey-two-states
January 25, 2010 - December 1, 2011
Are temporary staff associated with more severe emergency department
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psnet.ahrq.gov/issue/ismp-quarterwatch-reports
June 07, 2017 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
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psnet.ahrq.gov/issue/2017-ismp-medication-safety-self-assessment-communityambulatory-pharmacy
June 07, 2017 - May 11, 2017
Severe hyperglycemia in patients incorrectly using insulin pens at home.
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psnet.ahrq.gov/issue/patient-safety-24
December 01, 2011 - July 8, 2013
Are temporary staff associated with more severe emergency department medication
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psnet.ahrq.gov/issue/nursing-care-quality-nqf
September 06, 2011 - July 8, 2009
Antecedents of severe and nonsevere medication errors.
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psnet.ahrq.gov/node/49811/psn-pdf
November 01, 2017 - worsening respiratory status, liver abnormalities, and colonic pseudo-obstruction were all
consistent with severe … These are rare but life-threatening conditions that result from either decompensated
thyrotoxicosis or severe … Effects Score
Absent 0
Mild (agitation) 10
Moderate (delirium, psychosis, extreme lethargy) 20
Severe … 25
Congestive Heart Failure Score
Absent 0
Mild (pedal edema) 5
Moderate (bibasilar rales) 10
Severe
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.25_slideshow.ppt
July 01, 2003 - advanced care discussions
Case: Code Status Confusion
A 60-year-old woman with a history of severe … preferences in scenarios with uncertain outcomes
i.e., successful cardiac resuscitation with resultant severe
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psnet.ahrq.gov/issue/10-medication-safety-tips-hospitalized-patients
February 06, 2019 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
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psnet.ahrq.gov/issue/ismp-long-term-care-advise-err
June 07, 2017 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
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psnet.ahrq.gov/issue/clinical-issues-series
July 05, 2006 - 2006
National Partnership for Maternal Safety: consensus bundle on support after a severe
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psnet.ahrq.gov/issue/fatal-gas-line-mix-how-avoid-making-gastly-mistake
April 29, 2018 - September 12, 2016
ALERT: reports of severe harm after intravenous administration of