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psnet.ahrq.gov/node/47745/psn-pdf
March 06, 2019 - "I am administering medication—please do not interrupt
me": red tabards preventing interruptions as perceived by
surgical patients.
March 6, 2019
Palese A, Ferro M, Pascolo M, et al. "I Am Administering Medication-Please Do Not Interrupt Me": Red
Tabards Preventing Interruptions as Perceived by Surgical Patients. …
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psnet.ahrq.gov/node/837681/psn-pdf
September 11, 2023 - Compendium of Strategies to Prevent HAIs in Acute Care
Hospitals 2022.
September 11, 2023
Infect Control Hosp Epidemiol. 2022-2023.
https://psnet.ahrq.gov/issue/compendium-strategies-prevent-hais-acute-care-hospitals-2022
Health care–associated infections (HAIs) affect patients both during and after hospitalizatio…
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psnet.ahrq.gov/node/867012/psn-pdf
October 23, 2024 - Do healthcare professionals work around safety
standards, and should we be worried? A scoping review.
October 23, 2024
Clark D, Lawton R, Baxter R, et al. Do healthcare professionals work around safety standards, and should
we be worried? A scoping review. BMJ Qual Saf. 2024;Epub Sep 27. doi:10.1136/bmjqs-2024-0175…
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psnet.ahrq.gov/node/866685/psn-pdf
September 11, 2024 - Evaluation and mitigation of the limitations of large
language models in clinical decision-making.
September 11, 2024
Hager P, Jungmann F, Holland R, et al. Evaluation and mitigation of the limitations of large language
models in clinical decision-making. Nat Med. 2024;30(9):2613-2622. doi:10.1038/s41591-024-03097-…
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psnet.ahrq.gov/node/47349/psn-pdf
January 30, 2019 - Relationship of staff information sharing and advice
networks to patient safety outcomes.
January 30, 2019
Brewer BB, Carley KM, Benham-Hutchins MM, et al. Relationship of Staff Information Sharing and Advice
Networks to Patient Safety Outcomes. J Nurs Adm. 2018;48(9):437-444.
doi:10.1097/NNA.0000000000000646.
ht…
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psnet.ahrq.gov/node/866518/psn-pdf
January 01, 2025 - Hospital rating organizations' quality and patient safety
scores: analysis of result discrepancies.
August 14, 2024
Badr S, Nahle T, Rahman S, et al. Hospital rating organizations' quality and patient safety scores: analysis
of result discrepancies. J Gen Intern Med. 2025;40(3):525-531. doi:10.1007/s11606-024-08950…
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psnet.ahrq.gov/node/864853/psn-pdf
March 20, 2024 - Question answering systems for health professionals at
the point of care - a systematic review.
March 20, 2024
Kell G, Roberts A, Umansky S, et al. Question answering systems for health professionals at the point of
care—a systematic review. J Am Med Inform Assoc. 2024;31(4):1009-1024. doi:10.1093/jamia/ocae015.
h…
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psnet.ahrq.gov/node/72817/psn-pdf
March 10, 2021 - Assessment of patients' ability to review electronic health
record information to identify potential errors: cross-
sectional web-based survey.
March 10, 2021
Freise L, Neves AL, Flott K, et al. Assessment of patients' ability to review electronic health record
information to identify potential errors: cross-secti…
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psnet.ahrq.gov/node/867751/psn-pdf
March 12, 2025 - Epidemiology of diagnostic errors in pediatric emergency
departments using electronic triggers.
March 12, 2025
Mahajan P, White E, Shaw KN, et al. Epidemiology of diagnostic errors in pediatric emergency
departments using electronic triggers. Acad Emerg Med. 2025;Epub Jan 15. doi:10.1111/acem.15087.
https://psnet.…
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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
-
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
-
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