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psnet.ahrq.gov/node/45279/psn-pdf
September 27, 2016 - Does clinical supervision of health professionals improve
patient safety? A systematic review and meta-analysis.
September 27, 2016
Snowdon DA, Hau R, Leggat SG, et al. Does clinical supervision of health professionals improve patient
safety? A systematic review and meta-analysis. Int J Qual Health Care. 2016;28(4)…
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psnet.ahrq.gov/node/41212/psn-pdf
March 14, 2012 - A comprehensive overview of medical error in hospitals
using incident-reporting systems, patient complaints and
chart review of inpatient deaths.
March 14, 2012
de Feijter JM, de Grave WS, Muijtjens AM, et al. A comprehensive overview of medical error in hospitals
using incident-reporting systems, patient complain…
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psnet.ahrq.gov/node/46342/psn-pdf
October 04, 2017 - Improving reconciliation following medical injury: a
qualitative study of responses to patient safety incidents
in New Zealand.
October 4, 2017
Moore J, Mello MM. Improving reconciliation following medical injury: a qualitative study of responses to
patient safety incidents in New Zealand. BMJ Qual Saf. 2017;26(10…
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psnet.ahrq.gov/node/42298/psn-pdf
December 31, 2014 - Using statistical text classification to identify health
information technology incidents.
December 31, 2014
Chai KEK, Anthony S, Coiera E, et al. Using statistical text classification to identify health information
technology incidents. J Am Med Inform Assoc. 2013;20(5):980-5. doi:10.1136/amiajnl-2012-001409.
htt…
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psnet.ahrq.gov/node/45113/psn-pdf
May 11, 2016 - Medical error—the third leading cause of death in the US.
May 11, 2016
Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.
doi:10.1136/bmj.i2139.
https://psnet.ahrq.gov/issue/medical-error-third-leading-cause-death-us
How many patients die each year due to preventabl…
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psnet.ahrq.gov/node/73389/psn-pdf
June 16, 2021 - Estimating the economic cost of nurse sensitive adverse
events amongst patients in medical and surgical settings.
June 16, 2021
Murphy A, Griffiths P, Duffield C, et al. Estimating the economic cost of nurse sensitive adverse events
amongst patients in medical and surgical settings. J Adv Nurs. 2021;77(8):3379-3388…
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psnet.ahrq.gov/node/38164/psn-pdf
July 02, 2009 - A Compendium of Strategies to Prevent Healthcare-
Associated Infections in Acute Care Hospitals.
July 2, 2009
Yokoe DS, Mermel LA, Anderson DJ, et al. Infect Control Hosp Epidemiol. 2008;29:901-994.
https://psnet.ahrq.gov/issue/compendium-strategies-prevent-healthcare-associated-infections-acute-care-
hospi…
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psnet.ahrq.gov/node/38710/psn-pdf
September 14, 2009 - Patient readmissions, emergency visits, and adverse
events after software-assisted discharge from hospital:
cluster randomized trial.
September 14, 2009
Graumlich JF, Novotny NL, Nace S, et al. Patient readmissions, emergency visits, and adverse events after
software-assisted discharge from hospital: cluster rando…
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psnet.ahrq.gov/node/40146/psn-pdf
March 02, 2011 - Primary care–relevant interventions to prevent falling in
older adults: a systematic evidence review for the U.S.
Preventive Services Task Force.
March 2, 2011
Michael YL, Whitlock EP, Lin JS, et al. Primary care-relevant interventions to prevent falling in older adults:
a systematic evidence review for the U.S. P…
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psnet.ahrq.gov/node/45167/psn-pdf
May 25, 2016 - AHRQ Communication and Optimal Resolution (CANDOR)
Toolkit.
May 25, 2016
Rockville, MD: Agency for Healthcare Research and Quality; May 2016.
https://psnet.ahrq.gov/issue/ahrq-communication-and-optimal-resolution-candor-toolkit
Traditionally, health systems have disclosed adverse events to patients only through a …
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psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
September 01, 2017 - Thus, unforeseen events happened more frequently and were more severe than anyone predicted.( 12 ) Over … Most clinicians really want to be focused on severe reactions, "never" combinations, such as "never give
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psnet.ahrq.gov/node/838197/psn-pdf
September 28, 2022 - past medical history of ulcerative colitis was admitted for further evaluation of
ongoing diarrhea, 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
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psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - SPOTLIGHT CASE
Antiseizure Medication Disorder
Citation Text:
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/print/pdf/node/845971
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Value and Patient Safety
Curated Library
Foundations
Safety is the preservation of value.
Vandeskog B. J Safety Res. 2024;89:105-115.
Safety is at the heart of safety science, and yet “safety” lacks a consensus definition among safety
resea…
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psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
April 27, 2022 - Annual Perspective
Annual Perspective: Topics in Medication Safety
March 31, 2022
View more articles from the same authors.
Citation Text:
Harris IB, Dowell P, Mossburg SE. Annual Perspective: Topics in Medication Safety. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - The TPN was immediately stopped and the boy was given free water intravenously to correct the severe