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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.…
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psnet.ahrq.gov/node/61048/psn-pdf
October 21, 2020 - Streamlining care in crisis: rapid creation and
implementation of a digital support tool for COVID-19.
October 21, 2020
Stark N, Kerrissey M, Grade M, et al. Streamlining care in crisis: rapid creation and implementation of a
digital support tool for COVID-19. West J Emerg Med. 2020;21(5):1095-1101.
doi:10.5811/we…
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psnet.ahrq.gov/node/50823/psn-pdf
January 22, 2020 - Reducing inappropriate polypharmacy in primary care
through pharmacy-led interventions.
January 22, 2020
Bryant E, Claire K, Needham R. Reducing inappropriate polypharmacy in primary care through pharmacy-
led interventions. Pharm J. 2019;303(7932). doi:10.1211/pj.2019.20207385.
https://psnet.ahrq.gov/issue/reduci…
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psnet.ahrq.gov/node/866283/psn-pdf
July 10, 2024 - Safety and Quality of Parenteral Nutrition: Translating
Guidelines into Clinical Practice Considering Different
Organizational Settings.
July 10, 2024
Am J Health Syst Pharm. 2024;81(supp 3):s73-s136.
https://psnet.ahrq.gov/issue/safety-and-quality-parenteral-nutrition-translating-guidelines-clinical-practice-
co…
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psnet.ahrq.gov/node/36118/psn-pdf
September 24, 2010 - Implementing patient safety practices in small ambulatory
care settings.
September 24, 2010
Schauberger CW, Larson P. Implementing patient safety practices in small ambulatory care settings. Jt
Comm J Qual Patient Saf. 2006;32(8):419-425.
https://psnet.ahrq.gov/issue/implementing-patient-safety-practices-small-amb…
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psnet.ahrq.gov/node/47367/psn-pdf
October 15, 2018 - Themed Issue on Innovations in Medication Safety.
October 15, 2018
Kane-Gill SL. Innovations in Medication Safety: Services and Technologies to Enhance the Understanding
and Prevention of Adverse Drug Reactions. Pharmacotherapy. 2018;38(8):782-784.
doi:10.1002/phar.2154.
https://psnet.ahrq.gov/issue/themed-issue-i…
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psnet.ahrq.gov/node/34693/psn-pdf
February 10, 2011 - Effect of outcome on physician judgments of
appropriateness of care.
February 10, 2011
Caplan RA, Posner KL, Cheney FW. Effect of outcome on physician judgments of appropriateness of care.
JAMA. 1991;265(15):1957-60.
https://psnet.ahrq.gov/issue/effect-outcome-physician-judgments-appropriateness-care
The authors …
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psnet.ahrq.gov/node/44036/psn-pdf
April 15, 2015 - Can medical students identify a potentially serious
acetaminophen dosing error in a simulated encounter? A
case control study.
April 15, 2015
Dudas RA, Barone MA. Can medical students identify a potentially serious acetaminophen dosing error in a
simulated encounter? a case control study. BMC Med Educ. 2015;15(1).…
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psnet.ahrq.gov/node/837801/psn-pdf
August 10, 2022 - Decreasing misdiagnoses of urinary tract infections in a
pediatric emergency department.
August 10, 2022
Ostrow O, Prodanuk M, Foong Y, et al. Decreasing misdiagnoses of urinary tract infections in a pediatric
emergency department. Pediatrics. 2022;150(1):e2021055866. doi:10.1542/peds.2021-055866.
https://psnet.ah…
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psnet.ahrq.gov/node/836809/psn-pdf
March 30, 2022 - Pharmacist transition-of-care services improve patient
satisfaction and decrease hospital readmissions.
March 30, 2022
March KL, Peters MJ, Finch CK, et al. J Pharm Pract. 2022;35(1):86-93.
https://psnet.ahrq.gov/issue/pharmacist-transition-care-services-improve-patient-satisfaction-and-decrease-
hospital
Tr…
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psnet.ahrq.gov/node/41389/psn-pdf
June 27, 2012 - Can we make postoperative patient handovers safer? A
systematic review of the literature.
June 27, 2012
Segall N, Bonifacio AS, Schroeder RA, et al. Can we make postoperative patient handovers safer? A
systematic review of the literature. Anesth Analg. 2012;115(1):102-15.
doi:10.1213/ANE.0b013e318253af4b.
https:/…
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psnet.ahrq.gov/node/44373/psn-pdf
August 12, 2015 - Healthcare Utilizing Deliberate Discussion Linking Events
(HUDDLE): a systematic review.
August 12, 2015
Glymph DC, Olenick M, Barbera S, et al. Healthcare Utilizing Deliberate Discussion Linking Events
(HUDDLE): A Systematic Review. AANA J. 2015;83(3):183-188.
https://psnet.ahrq.gov/issue/healthcare-utilizing-del…