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psnet.ahrq.gov/issue/making-infusion-error-second-victims-infusion-therapy-related-medication-errors
June 27, 2018 - July 5, 2013
Guidance for health care leaders during the recovery stage of the COVID-
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psnet.ahrq.gov/issue/depth-investigation-causes-prescribing-errors-foundation-trainees-relation-their-medical
May 16, 2012 - Improving inpatient mental health medication safety through the process of obtaining HIMSS Stage
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psnet.ahrq.gov/issue/impact-care-quality-commission-provider-performance-room-improvement
November 18, 2015 - February 11, 2015
High Quality Care for All: NHS Next Stage Review Final Report.
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psnet.ahrq.gov/issue/improving-disclosure-and-management-medical-error-opportunity-transform-surgeons-tomorrow
April 11, 2012 - March 9, 2022
Guidance for health care leaders during the recovery stage of the COVID
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psnet.ahrq.gov/issue/potentially-inappropriate-prescribing-elderly-patients-2-outpatient-settings
November 18, 2009 - December 9, 2020
Anticoagulant safety takes center stage in 2007.
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psnet.ahrq.gov/issue/when-5-rights-go-wrong-medication-errors-nursing-perspective
June 27, 2018 - September 26, 2010
Guidance for health care leaders during the recovery stage of the
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psnet.ahrq.gov/issue/implementation-telepharmacy-service-provide-round-clock-medication-order-review-pharmacists
September 22, 2010 - Impact of health information technology on detection of potential adverse drug events at the ordering stage
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psnet.ahrq.gov/issue/devastatingly-human-analysis-registered-nurses-medication-error-accounts
June 27, 2018 - July 5, 2013
Guidance for health care leaders during the recovery stage of the COVID-
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psnet.ahrq.gov/issue/understanding-handling-drug-safety-alerts-simulation-study
March 04, 2011 - Impact of health information technology on detection of potential adverse drug events at the ordering stage
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psnet.ahrq.gov/issue/health-care-associated-infections-hospitals-continuing-leadership-needed-hhs-prioritize
September 06, 2016 - May 1, 2015
Hearing on Patient Safety and Quality Issues in End Stage Renal Disease Treatment
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psnet.ahrq.gov/issue/should-patients-have-role-patient-safety-safety-engineering-view
June 10, 2009 - April 18, 2018
Guidance for health care leaders during the recovery stage of the COVID
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psnet.ahrq.gov/issue/action-planning-tool-ahrq-surveys-patient-safety-culture
February 12, 2019 - October 5, 2015
AHRQ Safety Program for End-Stage Renal Disease Facilities—Toolkit.
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psnet.ahrq.gov/issue/patient-safety-outcomes-small-urban-and-small-rural-hospitals
July 23, 2010 - Impact of health information technology on detection of potential adverse drug events at the ordering stage
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psnet.ahrq.gov/node/46278/psn-pdf
July 19, 2017 - The opioid epidemic: what can surgeons do about it?
July 19, 2017
Saluja S, Selzer D, Meara JG, et al. Bull Am Coll Surg. 2017;102(7):13-18.
https://psnet.ahrq.gov/issue/opioid-epidemic-what-can-surgeons-do-about-it
Surgeons often prescribe opioids for patients after procedures, so they are in a key position to ass…
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psnet.ahrq.gov/node/47355/psn-pdf
September 05, 2018 - Preventing medication errors in the information age.
September 5, 2018
Godshall M, Riehl M. Preventing medication errors in the information age. Nursing (Brux). 2018;48(9):56-
58. doi:10.1097/01.NURSE.0000544230.51598.38.
https://psnet.ahrq.gov/issue/preventing-medication-errors-information-age
Failure to consider…
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psnet.ahrq.gov/node/45149/psn-pdf
September 19, 2016 - Care at the point of impact: insights into the second-
victim experience.
September 19, 2016
Scott SD, McCoig MM. Care at the point of impact: Insights into the second-victim experience. J Healthc
Risk Manag. 2016;35(4):6-13. doi:10.1002/jhrm.21218.
https://psnet.ahrq.gov/issue/care-point-impact-insights-second-vi…
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psnet.ahrq.gov/node/46926/psn-pdf
March 07, 2018 - A comprehensive program to reduce rates of hospital-
acquired pressure ulcers in a system of community
hospitals.
March 7, 2018
Englebright J, Westcott R, McManus K, et al. A Comprehensive Program to Reduce Rates of Hospital-
Acquired Pressure Ulcers in a System of Community Hospitals. J Patient Saf. 2018;14(1):54…
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psnet.ahrq.gov/node/42877/psn-pdf
January 22, 2014 - Identification of poor performance in a national medical
workforce over 11 years: an observational study.
January 22, 2014
Donaldson LJ, Panesar S, McAvoy PA, et al. Identification of poor performance in a national medical
workforce over 11 years: an observational study. BMJ Qual Saf. 2014;23(2):147-52. doi:10.1136…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
February 01, 2006 - Failure to Reach Correct Diagnosis
Pre-turnover stage
Clinicians content with diagnosis of urinary … Failure to Reach Correct Diagnosis
Meeting stage
It was unclear who was responsible for follow-up and
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psnet.ahrq.gov/node/39525/psn-pdf
March 13, 2019 - Effect of bar-code technology on the safety of medication
administration.
March 13, 2019
Poon EG, Keohane C, Yoon CS, et al. Effect of bar-code technology on the safety of medication
administration. New Engl J Med. 2010;362(18):1698-1707. doi:10.1056/NEJMsa0907115.
https://psnet.ahrq.gov/issue/effect-bar-code-tech…