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psnet.ahrq.gov/node/45857/psn-pdf
July 11, 2017 - Assessing the impact of the anesthesia medication
template on medication errors during anesthesia: a
prospective study.
July 11, 2017
Grigg EB, Martin LD, Ross FJ, et al. Assessing the Impact of the Anesthesia Medication Template on
Medication Errors During Anesthesia: A Prospective Study. Anesth Analg. 2017;124(5…
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psnet.ahrq.gov/node/47863/psn-pdf
May 22, 2019 - The dangers of ignoring the Beers criteria—the
prescribing cascade.
May 22, 2019
DeRhodes KH. The Dangers of Ignoring the Beers Criteria-The Prescribing Cascade. JAMA Intern Med.
2019;179(7):863-864. doi:10.1001/jamainternmed.2019.1288.
https://psnet.ahrq.gov/issue/dangers-ignoring-beers-criteria-prescribing-casca…
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psnet.ahrq.gov/node/45138/psn-pdf
May 25, 2016 - Improving Weekend Out Of Hours Surgical Handover
(WOOSH).
May 25, 2016
Boyer M, Tappenden J, Peter M. Improving Weekend Out Of hours Surgical Handover (WOOSH). BMJ
Qual Improv Rep. 2016;5(1):1-4. doi:10.1136/bmjquality.u209552.w4190.
https://psnet.ahrq.gov/issue/improving-weekend-out-hours-surgical-handover-woosh
…
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psnet.ahrq.gov/node/72759/psn-pdf
February 17, 2021 - Health Information Technology for Engaging Patients in
Diagnostic Decision Making in Emergency Departments.
February 17, 2021
Mangus CW, Singh H, Mahajan P. Rockville, MD: Agency for Healthcare Research and Quality; February
2021. AHRQ Publication No. 20(21)-0040-4-EF.
https://psnet.ahrq.gov/issue/health-info…
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psnet.ahrq.gov/node/36496/psn-pdf
February 28, 2011 - Literacy and misunderstanding prescription drug labels.
February 28, 2011
Davis TC, Wolf MS, Bass PF, et al. Literacy and misunderstanding prescription drug labels. Ann Intern
Med. 2006;145(12):887-94.
https://psnet.ahrq.gov/issue/literacy-and-misunderstanding-prescription-drug-labels
Poor health literacy has been…
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psnet.ahrq.gov/node/44290/psn-pdf
April 10, 2023 - Retained surgical sponge (gossypiboma) and other
retained surgical items: prevention and management.
April 10, 2023
Copeland AW. UpToDate. April 10, 2023.
https://psnet.ahrq.gov/issue/retained-surgical-sponge-gossypiboma-and-other-retained-surgical-items-
prevention-and
Retained surgical items are rare and potent…
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psnet.ahrq.gov/node/45539/psn-pdf
November 18, 2016 - Overuse of medical imaging and its radiation
exposure: who’s minding our children?
November 18, 2016
Schroeder AR, Duncan JR. Overuse of Medical Imaging and Its Radiation Exposure: Who's Minding Our
Children? JAMA Pediatr. 2016;170(11):1037-1038. doi:10.1001/jamapediatrics.2016.2147.
https://psnet.ahrq.gov/issue/o…
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psnet.ahrq.gov/node/47818/psn-pdf
April 03, 2019 - Medication safety in emergency medical services:
approaching an evidence-based method of verification to
reduce errors.
April 3, 2019
Misasi P, Keebler JR. Medication safety in emergency medical services: approaching an evidence-based
method of verification to reduce errors. Ther Adv Drug Saf. 2019;10:204209861882…
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psnet.ahrq.gov/node/47790/psn-pdf
April 08, 2019 - The "hemolyzed" physical examination—situational
challenges to accurate bedside diagnosis.
April 8, 2019
Sargsyan Z. The "Hemolyzed" Physical Examination-Situational Challenges to Accurate Bedside
Diagnosis. JAMA Intern Med. 2019;179(4):465-466. doi:10.1001/jamainternmed.2018.8753.
https://psnet.ahrq.gov/issue/hem…
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psnet.ahrq.gov/node/45815/psn-pdf
January 25, 2017 - Handoffs: transitions of care for children in the
emergency department.
January 25, 2017
American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of
Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association
Pediatric Committee. Pediatrics. 2016;138:…
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psnet.ahrq.gov/node/47995/psn-pdf
July 24, 2019 - Standardising the classification of harm associated with
medication errors: the Harm Associated with Medication
Error Classification (HAMEC).
July 24, 2019
Gates PJ, Baysari M, Mumford V, et al. Standardising the Classification of Harm Associated with
Medication Errors: The Harm Associated with Medication Error Cl…
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psnet.ahrq.gov/node/47400/psn-pdf
November 28, 2018 - Impact of the communication and patient hand-off tool
SBAR on patient safety: a systematic review.
November 28, 2018
Müller M, Jürgens J, Redaèlli M, et al. Impact of the communication and patient hand-off tool SBAR on
patient safety: a systematic review. BMJ Open. 2018;8(8):e022202. doi:10.1136/bmjopen-2018-022202…
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psnet.ahrq.gov/node/41606/psn-pdf
February 01, 2019 - Safe use of opioids in hospitals.
December 23, 2016
Sentinel Event Alert. 2012;49:1-5.
https://psnet.ahrq.gov/issue/safe-use-opioids-hospitals
Opioid pain medications are considered high-risk medications due to the potential for respiratory
depression and other adverse effects. Because these medications are freque…
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psnet.ahrq.gov/node/73984/psn-pdf
October 20, 2021 - Analyzing diagnostic errors in the acute setting: a
process-driven approach.
October 20, 2021
Griffin JA, Carr K, Bersani K, et al. Analyzing diagnostic errors in the acute setting: a process-driven
approach. Diagnosis (Berl). 2022;9(1):77-88. doi:10.1515/dx-2021-0033.
https://psnet.ahrq.gov/issue/analyzing-diagno…
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psnet.ahrq.gov/node/45031/psn-pdf
February 18, 2017 - Information transfer in multidisciplinary operating room
teams: a simulation-based observational study.
February 18, 2017
Cumin D, Skilton C, Weller J. Information transfer in multidisciplinary operating room teams: a simulation-
based observational study. BMJ Qual Saf. 2017;26(3):209-216. doi:10.1136/bmjqs-2015-00…
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psnet.ahrq.gov/node/866814/psn-pdf
September 25, 2024 - Accuracy of a proprietary large language model in
labeling obstetric incident reports.
September 25, 2024
Johnson J, Brown C, Lee GM, et al. Accuracy of a proprietary large language model in labeling obstetric
incident reports. Jt Comm J Qual Patient Saf. 2024;50(12):877-881. doi:10.1016/j.jcjq.2024.08.001.
https:…
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psnet.ahrq.gov/node/43500/psn-pdf
November 17, 2014 - A systematic review of behavioural marker systems in
healthcare: what do we know about their attributes,
validity and application?
November 17, 2014
Dietz AS, Pronovost P, Benson KN, et al. A systematic review of behavioural marker systems in
healthcare: what do we know about their attributes, validity and applica…
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psnet.ahrq.gov/node/45573/psn-pdf
November 16, 2016 - High reliability of care in orthopedic surgery: are we there
yet?
November 16, 2016
Anoushiravani AA, Sayeed Z, El-Othmani MM, et al. High Reliability of Care in Orthopedic Surgery: Are We
There Yet? Orthop Clin North Am. 2016;47(4):689-95. doi:10.1016/j.ocl.2016.05.011.
https://psnet.ahrq.gov/issue/high-reliabili…
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psnet.ahrq.gov/node/44253/psn-pdf
August 24, 2015 - Acceptability and feasibility of the Leapfrog computerized
physician order entry evaluation tool for hospitals outside
the United States.
August 24, 2015
Cho IS, Lee J-H, Choi S-K, et al. Acceptability and feasibility of the Leapfrog computerized physician order
entry evaluation tool for hospitals outside the Unit…
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psnet.ahrq.gov/node/41206/psn-pdf
March 14, 2012 - SBAR M&M: a feasible, reliable, and valid tool to assess
the quality of, surgical morbidity and mortality conference
presentations.
March 14, 2012
Mitchell EL, Lee DY, Arora S, et al. SBAR M&M: a feasible, reliable, and valid tool to assess the quality of,
surgical morbidity and mortality conference presentations.…