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psnet.ahrq.gov/node/39974/psn-pdf
June 27, 2011 - How are medication errors defined? A systematic
literature review of definitions and characteristics.
June 27, 2011
Lisby M, Nielsen LP, Brock B, et al. How are medication errors defined? A systematic literature review of
definitions and characteristics. International Journal for Quality in Health Care. 2010;22(6).…
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psnet.ahrq.gov/node/45986/psn-pdf
March 29, 2017 - Pediatric prehospital medication dosing errors: a national
survey of paramedics.
March 29, 2017
Hoyle JD, Crowe RP, Bentley MA, et al. Pediatric prehospital medication dosing errors: a national survey of
paramedics. Prehosp Emerg Care. 2017;21(2):185-191. doi:10.1080/10903127.2016.1227001.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/45981/psn-pdf
June 21, 2017 - State sepsis mandates—a new era for regulation of
hospital quality.
June 21, 2017
Hershey TB, Kahn JM. State Sepsis Mandates - A New Era for Regulation of Hospital Quality. N Engl J
Med. 2017;376(24):2311-2313. doi:10.1056/NEJMp1611928.
https://psnet.ahrq.gov/issue/state-sepsis-mandates-new-era-regulation-hospital…
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psnet.ahrq.gov/node/38907/psn-pdf
January 03, 2017 - Applying Toyota Production System principles to a
psychiatric hospital: making transfers safer and more
timely.
January 3, 2017
Young JQ, Wachter R. Applying Toyota Production System principles to a psychiatric hospital: making
transfers safer and more timely. Jt Comm J Qual Patient Saf. 2009;35(9):439-448.
https…
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psnet.ahrq.gov/node/43781/psn-pdf
March 14, 2016 - Nurses' perspectives regarding the disclosure of errors to
patients: a qualitative study.
March 14, 2016
McLennan SR, Diebold M, Rich LE, et al. Nurses' perspectives regarding the disclosure of errors to
patients: A qualitative study. Int J Nurs Stud. 2016;54:16-22. doi:10.1016/j.ijnurstu.2014.10.001.
https://psne…
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psnet.ahrq.gov/node/38356/psn-pdf
January 21, 2009 - Oxytocin as a high-alert medication: implications for
perinatal patient safety.
January 21, 2009
Simpson KR, Knox E. Oxytocin as a high-alert medication: implications for perinatal patient safety. MCN
Am J Matern Child Nurs. 2009;34(1):8-15; quiz 16-7. doi:10.1097/01.NMC.0000343859.62828.ee.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/45985/psn-pdf
March 29, 2017 - Building a high-reliability organization: one system's
patient safety journey.
March 29, 2017
Building a high-reliability organization: one system's patient safety journey. J Healthc Manag. 2017;62.
https://psnet.ahrq.gov/issue/building-high-reliability-organization-one-systems-patient-safety-journey
High reliabil…
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psnet.ahrq.gov/node/836784/psn-pdf
March 23, 2022 - Qualitative content analysis: a framework for the
substantive review of hospital incident reports.
March 23, 2022
Stephens S. Qualitative content analysis: a framework for the substantive review of hospital incident
reports. J Healthc Risk Manag. 2022;41(4):17-26. doi:10.1002/jhrm.21498.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/41388/psn-pdf
May 30, 2012 - Observational teamwork assessment for surgery:
feasibility of clinical and nonclinical assessor calibration
with short-term training.
May 30, 2012
Russ S, Hull L, Rout S, et al. Observational teamwork assessment for surgery: feasibility of clinical and
nonclinical assessor calibration with short-term training. Ann…
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psnet.ahrq.gov/node/34750/psn-pdf
May 21, 2019 - The Basics of FMEA. 2nd ed.
May 21, 2019
McDermott RE, Mikulak RJ, Beauregard MR. New York, NY: CRC Press; 2009. ISBN: 9781563273773.
https://psnet.ahrq.gov/issue/basics-fmea-2nd-edition
The authors provide a handbook that serves as the core tool for understanding and implementing the
failure mode and effect analy…
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psnet.ahrq.gov/node/42698/psn-pdf
December 04, 2013 - A structured judgement method to enhance mortality
case note review: development and evaluation.
December 4, 2013
Hutchinson A, Coster JE, Cooper KL, et al. A structured judgement method to enhance mortality case note
review: development and evaluation. BMJ Qual Saf. 2013;22(12). doi:10.1136/bmjqs-2013-001839.
htt…
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psnet.ahrq.gov/node/35574/psn-pdf
June 17, 2010 - What do we know about financial returns on investments
in patient safety? A literature review.
June 17, 2010
Schmidek JM, Weeks WB. What do we know about financial returns on investments in patient safety? A
literature review. Jt Comm J Qual Patient Saf. 2005;31(12):690-699.
https://psnet.ahrq.gov/issue/what-do-we…
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psnet.ahrq.gov/node/46221/psn-pdf
July 02, 2017 - Tools and methods for quality improvement and patient
safety in perinatal care.
July 2, 2017
Nathan AT, Kaplan HC. Tools and methods for quality improvement and patient safety in perinatal care.
Semin Perinatol. 2017;41(3):142-150. doi:10.1053/j.semperi.2017.03.002.
https://psnet.ahrq.gov/issue/tools-and-methods-q…
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psnet.ahrq.gov/node/45557/psn-pdf
October 27, 2016 - Time-out: the professional and organizational ethics of
speaking up in the OR.
October 27, 2016
Berlinger N, Dietz E. Time-out: The Professional and Organizational Ethics of Speaking Up in the OR. AMA
J Ethics. 2016;18(9):925-32. doi:10.1001/journalofethics.2016.18.9.stas1-1609.
https://psnet.ahrq.gov/issue/time-o…
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psnet.ahrq.gov/node/45611/psn-pdf
May 27, 2025 - Funding Announcement for Projects Targeting the
Reduction of Healthcare-Associated Infections.
July 7, 2021
Rockville, MD: Agency for Healthcare Research and Quality; July 7 2021.
https://psnet.ahrq.gov/issue/funding-announcement-projects-targeting-reduction-healthcare-associated-
infections
Health care–associate…
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psnet.ahrq.gov/node/47433/psn-pdf
February 22, 2019 - Impact of nurse peer review on a culture of safety.
February 22, 2019
Herrington CR, Hand MW. Impact of Nurse Peer Review on a Culture of Safety. J Nurs Care Qual.
2019;34(2):158-162. doi:10.1097/NCQ.0000000000000361.
https://psnet.ahrq.gov/issue/impact-nurse-peer-review-culture-safety
This commentary describes an…
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psnet.ahrq.gov/node/44630/psn-pdf
February 15, 2017 - Reduction of incorrect record accessing and charting
patient electronic medical records in the perioperative
environment.
February 15, 2017
Rebello E, Kee S, Kowalski A, et al. Reduction of incorrect record accessing and charting patient electronic
medical records in the perioperative environment. Health Informati…
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psnet.ahrq.gov/node/47218/psn-pdf
January 09, 2019 - The accuracy of medical dispatch—a systematic review.
January 9, 2019
Bohm K, Kurland L. The accuracy of medical dispatch - a systematic review. Scand J Trauma Resusc
Emerg Med. 2018;26(1):94. doi:10.1186/s13049-018-0528-8.
https://psnet.ahrq.gov/issue/accuracy-medical-dispatch-systematic-review
Medical dispatch i…
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psnet.ahrq.gov/node/42678/psn-pdf
February 21, 2015 - The reliability of AHRQ Common Format Harm Scales in
rating patient safety events.
February 21, 2015
Williams TL, Szekendi MK, Pavkovic S, et al. The reliability of AHRQ Common Format Harm Scales in
rating patient safety events. J Patient Saf. 2015;11(1):52-59. doi:10.1097/PTS.0b013e3182948ef9.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/44401/psn-pdf
November 20, 2015 - Medication reconciliation at admission and discharge: an
analysis of prevalence and associated risk factors.
November 20, 2015
Belda-Rustarazo S, Cantero-Hinojosa J, Salmeron-García A, et al. Medication reconciliation at admission
and discharge: an analysis of prevalence and associated risk factors. Int J Clin Prac…