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psnet.ahrq.gov/node/867009/psn-pdf
October 23, 2024 - Specialized nurses' role in ensuring patient safety within
the context of telehealth in home care: a scoping review.
October 23, 2024
Vaismoradi M, Rae J, Turunen H, et al. Specialized nurses’ role in ensuring patient safety within the
context of telehealth in home care: a scoping review. Digit Health. 2024;10:2055…
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psnet.ahrq.gov/node/60315/psn-pdf
May 13, 2020 - Safety at the time of the COVID-19 pandemic: how to keep
our oncology patients and healthcare workers safe.
May 13, 2020
Cinar P, Kubal T, Freifeld A, et al. Safety at the time of the COVID-19 pandemic: how to keep our oncology
patients and healthcare workers safe. J Natl Compr Canc Netw. 2020;18(5):504-509.
doi:1…
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psnet.ahrq.gov/node/43533/psn-pdf
August 28, 2017 - Organizational, cultural, and psychological determinants
of smart infusion pump work arounds: a study of 3 U.S.
health systems.
August 28, 2017
Dunford BB, Perrigino M, Tucker SJ, et al. Organizational, Cultural, and Psychological Determinants of
Smart Infusion Pump Work Arounds: A Study of 3 U.S. Health Systems. …
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psnet.ahrq.gov/node/38288/psn-pdf
February 03, 2011 - Hospital-wide code rates and mortality before and after
implementation of a rapid response team.
February 3, 2011
Chan PS, Khalid A, Longmore LS, et al. Hospital-wide code rates and mortality before and after
implementation of a rapid response team. JAMA. 2008;300(21):2506-13. doi:10.1001/jama.2008.715.
https://ps…
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psnet.ahrq.gov/node/47579/psn-pdf
December 12, 2018 - A prescription for enhancing electronic prescribing
safety.
December 12, 2018
Schiff G, Mirica MM, Dhavle AA, et al. A Prescription For Enhancing Electronic Prescribing Safety. Health
Aff (Millwood). 2018;37(11):1877-1883. doi:10.1377/hlthaff.2018.0725.
https://psnet.ahrq.gov/issue/prescription-enhancing-electroni…
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psnet.ahrq.gov/node/43378/psn-pdf
August 14, 2014 - Interventions to reduce pediatric medication errors: a
systematic review.
August 14, 2014
Rinke ML, Bundy DG, Velasquez CA, et al. Interventions to reduce pediatric medication errors: a
systematic review. Pediatrics. 2014;134(2):338-360. doi:10.1542/peds.2013-3531.
https://psnet.ahrq.gov/issue/interventions-reduce…
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psnet.ahrq.gov/node/39873/psn-pdf
January 22, 2017 - A proactive risk avoidance system using failure mode and
effects analysis for "same-name" physician orders.
January 22, 2017
Tarpey K, Schaaf E, Lakhani U, et al. A proactive risk avoidance system using failure mode and effects
analysis for "same-name" physician orders. Jt Comm J Qual Patient Saf. 2010;36(10):461-7…
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psnet.ahrq.gov/node/45101/psn-pdf
July 01, 2017 - A systematic review of patient safety measures in adult
primary care.
July 1, 2017
Hatoun J, Chan J, Yaksic E, et al. A Systematic Review of Patient Safety Measures in Adult Primary Care.
Am J Med Qual. 2017;32(3):237-245. doi:10.1177/1062860616644328.
https://psnet.ahrq.gov/issue/systematic-review-patient-safety-…
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psnet.ahrq.gov/node/46302/psn-pdf
December 22, 2017 - Non–health care facility medication errors resulting in
serious medical outcomes.
December 22, 2017
Hodges NL, Spiller HA, Casavant MJ, et al. Non-health care facility medication errors resulting in serious
medical outcomes. Clin Toxicol (Phila). 2018;56(1):43-50. doi:10.1080/15563650.2017.1337908.
https://psnet.a…
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psnet.ahrq.gov/node/37687/psn-pdf
February 22, 2011 - Use of an interactive, telephone-based self-management
support program to identify adverse events among
ambulatory diabetes patients.
February 22, 2011
Sarkar U, Handley MA, Gupta R, et al. Use of an interactive, telephone-based self-management support
program to identify adverse events among ambulatory diabetes p…
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psnet.ahrq.gov/node/47973/psn-pdf
July 18, 2019 - Transition planning for the senior surgeon: guidance and
recommendations from the Society of Surgical Chairs.
July 18, 2019
Rosengart TK, Doherty G, Higgins R, et al. Transition Planning for the Senior Surgeon: Guidance and
Recommendations From the Society of Surgical Chairs. JAMA Surg. 2019;154(7):647-653.
doi:10…
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psnet.ahrq.gov/node/40695/psn-pdf
December 31, 2014 - Factors contributing to an increase in duplicate
medication order errors after CPOE implementation.
December 31, 2014
Wetterneck TB, Walker JM, Blosky MA, et al. Factors contributing to an increase in duplicate medication
order errors after CPOE implementation. J Am Med Inform Assoc. 2011;18(6):774-782.
doi:10.113…
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psnet.ahrq.gov/node/40526/psn-pdf
June 15, 2011 - Critical drug–drug interactions for use in electronic health
records systems with computerized physician order
entry: review of leading approaches.
June 15, 2011
Classen DC, Phansalkar S, Bates DW. Critical Drug-Drug Interactions for Use in Electronic Health Records
Systems With Computerized Physician Order Entry.…
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psnet.ahrq.gov/node/37096/psn-pdf
June 24, 2010 - Impact of diagnosis-timing indicators on measures of
safety, comorbidity, and case mix groupings from
administrative data sources.
June 24, 2010
Naessens JM, Campbell CR, Berg B, et al. Impact of diagnosis-timing indicators on measures of safety,
comorbidity, and case mix groupings from administrative data sources…
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psnet.ahrq.gov/node/40819/psn-pdf
January 07, 2015 - Multimodal system designed to reduce errors in recording
and administration of drugs in anaesthesia: prospective
randomised clinical evaluation.
January 7, 2015
Merry A, Webster CS, Hannam J, et al. Multimodal system designed to reduce errors in recording and
administration of drugs in anaesthesia: prospective ran…
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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