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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867986/psn-pdf
    March 24, 2025 - In Conversation with Edwin Boudreaux about Suicide Prevention March 24, 2025 Boudreaux E, Gale B, Mossburg SE. In Conversation with Edwin Boudreaux about Suicide Prevention. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention Editor’s note: Edwin Boudre…
  2. psnet.ahrq.gov/innovation/implementing-watcher-program-improve-timeliness-recognition-deterioration-hospitalized
    June 30, 2021 - EMERGING INNOVATIONS Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children Citation Text: Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children Evans S, Green A, Roberson A, et al. …
  3. psnet.ahrq.gov/issue/using-harm-based-weights-ahrq-patient-safety-selected-indicators-composite-psi-90-does-it
    March 15, 2016 - Study Using harm-based weights for the AHRQ Patient Safety for Selected Indicators composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health Administration hospitals? Citation Text: Chen Q, Rosen AK, Borzecki A, et al. Using Harm-Bas…
  4. psnet.ahrq.gov/innovation/awareness-human-factors-operating-theatres-during-covid-19-pandemic
    January 13, 2021 - EMERGING INNOVATIONS Awareness of human factors in the operating theatres during the COVID-19 pandemic Citation Text: Britton CR, Hayman G, Stroud N. Awareness of Human Factors in the operating theatres during the COVID-19 pandemic. Journal of Perioperative Practice. 2020;31(1-2). doi:10.1177/1750…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865718/psn-pdf
    May 01, 2024 - Calculating the cost of medication errors: a systematic review of approaches and cost variables. May 1, 2024 Ranasinghe S, Nadeshkumar A, Senadheera S, et al. Calculating the cost of medication errors: a systematic review of approaches and cost variables. BMJ Open Qual. 2024;13(2):e002570. doi:10.1136/bmjoq-2023-0…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50907/psn-pdf
    February 19, 2020 - Oral chemotherapy: a home safety educational framework for healthcare providers, patients, and caregivers. February 19, 2020 Huff C. Oral chemotherapy: A home safety educational framework for healthcare providers, patients, and caregivers. Clin J Oncol Nurs. 2020;24(1):22-30. doi:10.1188/20.cjon.22-30. https://psn…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47119/psn-pdf
    September 19, 2018 - A usability and safety analysis of electronic health records: a multi-center study. September 19, 2018 Ratwani RM, Savage E, Will A, et al. A usability and safety analysis of electronic health records: a multi- center study. J Am Med Inform Assoc. 2018;25(9):1197-1201. doi:10.1093/jamia/ocy088. https://psnet.ahrq.…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43153/psn-pdf
    May 07, 2014 - Is oral chemotherapy prescription safe for patients? A cross-sectional survey. May 7, 2014 Bourmaud A, Pacaut C, Melis A, et al. Is oral chemotherapy prescription safe for patients? A cross- sectional survey. Ann Oncol. 2014;25(2):500-504. doi:10.1093/annonc/mdt553. https://psnet.ahrq.gov/issue/oral-chemotherapy-p…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848088/psn-pdf
    April 26, 2023 - Safety Risk of Air Embolus Associated with Central Venous Catheters Used for Haemodialysis Treatment. April 26, 2023 Farnborough, UK: Healthcare Safety Investigation Branch. March 2023. https://psnet.ahrq.gov/issue/safety-risk-air-embolus-associated-central-venous-catheters-used- haemodialysis-treatment Patients …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46676/psn-pdf
    December 13, 2017 - Diagnostic errors by medical students: results of a prospective qualitative study. December 13, 2017 Braun LT, Zwaan L, Kiesewetter J, et al. Diagnostic errors by medical students: results of a prospective qualitative study. BMC Med Educ. 2017;17(1):191. doi:10.1186/s12909-017-1044-7. https://psnet.ahrq.gov/issue/…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45253/psn-pdf
    October 03, 2017 - Patient safety: disclosure of medical errors and risk mitigation. October 3, 2017 Moffatt-Bruce SD, Ferdinand FD, Fann J. Patient Safety: Disclosure of Medical Errors and Risk Mitigation. Ann Thorac Surg. 2016;102(2):358-62. doi:10.1016/j.athoracsur.2016.06.033. https://psnet.ahrq.gov/issue/patient-safety-disclosu…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44772/psn-pdf
    January 13, 2016 - Post event debriefs: a commitment to learning how to better care for patients and staff. January 13, 2016 Campbell M, Miller K, McNicholas KW. Post Event Debriefs: A Commitment to Learning How to Better Care for Patients and Staff. Jt Comm J Qual Patient Saf. 2016;42(1):41-47. https://psnet.ahrq.gov/issue/post-eve…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42672/psn-pdf
    October 23, 2013 - SBAR improves nurse–physician communication and reduces unexpected death: a pre and post intervention study. October 23, 2013 De Meester K, Verspuy M, Monsieurs KG, et al. SBAR improves nurse-physician communication and reduces unexpected death: a pre and post intervention study. Resuscitation. 2013;84(9):1192-6. …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866561/psn-pdf
    August 21, 2024 - Medical malpractice litigation and daylight saving time. August 21, 2024 Gao C, Lage C, Scullin MK. Medical malpractice litigation and daylight saving time. J Clin Sleep Med. 2024;20(6):933-940. doi:10.5664/jcsm.11038. https://psnet.ahrq.gov/issue/medical-malpractice-litigation-and-daylight-saving-time Sleep depri…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45246/psn-pdf
    August 15, 2016 - Reliability of verbal handoff assessment and handoff quality before and after implementation of a resident handoff bundle. August 15, 2016 Feraco AM, Starmer AJ, Sectish TC, et al. Reliability of Verbal Handoff Assessment and Handoff Quality Before and After Implementation of a Resident Handoff Bundle. Acad Pediat…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35990/psn-pdf
    September 17, 2010 - Misunderstanding of prescription drug warning labels among patients with low literacy. September 17, 2010 Wolf MS, Davis TC, Tilson HH, et al. Misunderstanding of prescription drug warning labels among patients with low literacy. Am J Health Syst Pharm. 2006;63(11):1048-55. https://psnet.ahrq.gov/issue/misundersta…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38228/psn-pdf
    July 14, 2010 - Timely follow-up of abnormal outpatient test results: perceived barriers and impact on patient safety. July 14, 2010 Moore C, Saigh O, Trikha A, et al. Timely Follow-Up of Abnormal Outpatient Test Results. J Patient Saf. 2008;4(4):241-244. doi:10.1097/pts.0b013e31818d1ca4. https://psnet.ahrq.gov/issue/timely-follo…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40343/psn-pdf
    December 21, 2014 - Trends in central line–associated bloodstream infections in a trauma-surgical intensive care unit. December 21, 2014 Ong A, Dysert K, Herbert C, et al. Trends in central line-associated bloodstream infections in a trauma- surgical intensive care unit. Arch Surg. 2011;146(3):302-7. doi:10.1001/archsurg.2011.9. http…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47503/psn-pdf
    October 24, 2018 - I-PASS checklist: a powerful tool for patient handoffs. October 24, 2018 Peeples L. Pharmacy Practice News. October 10, 2018. https://psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs Structured handoffs can reduce communication problems that contribute to medical error. This magazine article re…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855438/psn-pdf
    November 15, 2023 - Intravenous (IV) push medications – bridging the gap between education and clinical practice. November 15, 2023 ISMP Medication Safety Alert! Acute Care. November 2, 2023;28(22):1-4. https://psnet.ahrq.gov/issue/intravenous-iv-push-medications-bridging-gap-between-education-and-clinical- practice Intravenous…

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