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psnet.ahrq.gov/node/74865/psn-pdf
February 23, 2022 - Latent safety threats and countermeasures in the
operating theater: a national in situ simulation-based
observational study.
February 23, 2022
Long JA, Webster CS, Holliday T, et al. Latent safety threats and countermeasures in the operating theater:
a national in situ simulation-based observational study. Simul H…
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psnet.ahrq.gov/node/44207/psn-pdf
August 21, 2018 - U.S. compounding pharmacy-related outbreaks, 2001--
2013: public health and patient safety lessons learned.
August 21, 2018
Shehab N, Brown MN, Kallen AJ, et al. U.S. compounding pharmacy-related outbreaks, 2001--2013: public
health and patient safety lessons learned. J Patient Saf. 2018;14(3):164-173.
doi:10.1097…
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psnet.ahrq.gov/node/866107/psn-pdf
June 12, 2024 - Hospital inpatient nutrition service errors and patient
safety interventions: a scoping review.
June 12, 2024
Austria D, McConnell C, Pope C. Hospital inpatient nutrition service errors and patient safety interventions:
a scoping review. J Patient Saf. 2024;20(4):272-278. doi:10.1097/pts.0000000000001223.
https://…
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psnet.ahrq.gov/node/843085/psn-pdf
January 25, 2023 - Assessment of the use of patient vital sign data for
preventing misidentification and medical errors.
January 25, 2023
Maul J, Straub J. Assessment of the use of patient vital sign data for preventing misidentification and
medical errors. Healthcare (Basel). 2022;10(12):2440. doi:10.3390/healthcare10122440.
https:…
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psnet.ahrq.gov/node/853622/psn-pdf
January 01, 2024 - Enhancing patient safety: a national standard for cyber
resiliency in healthcare.
September 20, 2023
Samuelson-Kiraly C, Mitchell JI, Kingston D, et al. Enhancing patient safety: A national standard for cyber
resiliency in healthcare. Healthc Manage Forum. 2024;37(1):9-12. doi:10.1177/08404704231196138.
https://ps…
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psnet.ahrq.gov/node/866163/psn-pdf
June 19, 2024 - Performance evaluation of ChatGPT in detecting
diagnostic errors and their contributing factors: an
analysis of 545 case reports of diagnostic errors.
June 19, 2024
Harada Y, Suzuki T, Harada T, et al. Performance evaluation of ChatGPT in detecting diagnostic errors
and their contributing factors: an analysis of 5…
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psnet.ahrq.gov/node/47476/psn-pdf
February 13, 2019 - Facilitated self-reported anaesthetic medication errors
before and after implementation of a safety bundle and
barcode-based safety system.
February 13, 2019
Bowdle TA, Jelacic S, Nair B, et al. Facilitated self-reported anaesthetic medication errors before and after
implementation of a safety bundle and barcode-b…
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psnet.ahrq.gov/node/46133/psn-pdf
May 24, 2017 - Implementing smart infusion pumps with dose-error
reduction software: real-world experiences.
May 24, 2017
Heron C. Implementing smart infusion pumps with dose-error reduction software: real-world experiences.
Br J Nurs. 2017;26(8):S13-S16. doi:10.12968/bjon.2017.26.8.S13.
https://psnet.ahrq.gov/issue/implementing…
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psnet.ahrq.gov/node/45021/psn-pdf
April 06, 2016 - Scandal as a sentinel event—recognizing hidden
cost–quality trade-offs.
April 6, 2016
Bloche G. Scandal as a Sentinel Event--Recognizing Hidden Cost-Quality Trade-offs. N Engl J Med.
2016;374(11):1001-3. doi:10.1056/NEJMp1502629.
https://psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-t…
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www.ahrq.gov/pqmp/measures/child-hcahps.html
August 01, 2021 - Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS)
Measure Domain: Patient-Reported Outcomes (Health Outcomes and Patient Experiences of Care)
Measure Sub-Domain: Patient Experience
PQMP COE: CEPQM
Associated NQF # and Name: 2548, Child Hospital CAHPS (HCAHPS)
Rela…
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psnet.ahrq.gov/node/41186/psn-pdf
January 03, 2017 - The costs of adverse drug events in community hospitals.
January 3, 2017
Hug BL, Keohane C, Seger DL, et al. The costs of adverse drug events in community hospitals. Jt Comm J
Qual Patient Saf. 2012;38(3):120-6.
https://psnet.ahrq.gov/issue/costs-adverse-drug-events-community-hospitals
Adverse drug events (ADEs) a…
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psnet.ahrq.gov/node/73588/psn-pdf
August 11, 2021 - Reporting of death in US Food and Drug Administration
medical device adverse event reports in categories other
than death.
August 11, 2021
Lalani C, Kunwar EM, Kinard M, et al. Reporting of death in US Food and Drug Administration medical
device adverse event reports in categories other than death. JAMA Intern Med…
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psnet.ahrq.gov/node/44033/psn-pdf
April 22, 2015 - Quality improvements in decreasing medication
administration errors made by nursing staff in an
academic medical center hospital: a trend analysis during
the journey to Joint Commission International
accreditation and in the post-accreditation era.
April 22, 2015
Wang H-F, Jin J-F, Feng X-Q, et al. Quality improv…
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psnet.ahrq.gov/node/840149/psn-pdf
November 16, 2022 - Developing strategic recommendations for implementing
smart pumps in advanced healthcare systems to improve
intravenous medication safety.
November 16, 2022
Sutherland A, Jones MD, Howlett M, et al. Developing strategic recommendations for implementing smart
pumps in advanced healthcare systems to improve intraven…
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psnet.ahrq.gov/node/47608/psn-pdf
March 20, 2019 - Use of a public health law framework to improve
medication safety by anesthesia providers.
March 20, 2019
Litman RS. Use of a public health law framework to improve medication safety by anesthesia providers. J
Patient Saf Risk Manag. 2019;24(4):158-165. doi:10.1177/2516043518825383.
https://psnet.ahrq.gov/issue/us…
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psnet.ahrq.gov/node/73567/psn-pdf
August 04, 2021 - Pharmacist-led educational interventions provided to
healthcare providers to reduce medication errors: a
systematic review and meta-analysis.
August 4, 2021
Jaam M, Naseralallah LM, Hussain TA, et al. Pharmacist-led educational interventions provided to
healthcare providers to reduce medication errors: a systemati…
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psnet.ahrq.gov/node/46631/psn-pdf
March 20, 2018 - Simulation-based education to ensure provider
competency within the healthcare system.
March 20, 2018
Griswold S, Fralliccardi A, Boulet J, et al. Simulation-based Education to Ensure Provider Competency
Within the Health Care System. Acad Emerg Med. 2018;25(2):168-176. doi:10.1111/acem.13322.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/60022/psn-pdf
March 11, 2020 - Work system barriers and facilitators in inpatient care
transitions of pediatric trauma patients.
March 11, 2020
Wooldridge AR, Carayon P, Hoonakker P, et al. Work system barriers and facilitators in inpatient care
transitions of pediatric trauma patients. App Ergon. 2020;85:103059. doi:10.1016/j.apergo.2020.103059…
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psnet.ahrq.gov/node/865873/psn-pdf
May 15, 2024 - A review of medication errors and the second victim in
pediatric pharmacy.
May 15, 2024
Bredenkamp K, Raschka MJ, Holmes A. A review of medication errors and the second victim in pediatric
pharmacy. J Pediatr Pharmacol Ther. 2024;29(2):100-106. doi:10.5863/1551-6776-29.2.100.
https://psnet.ahrq.gov/issue/review-me…
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psnet.ahrq.gov/node/47046/psn-pdf
April 18, 2018 - Smart pumps in practice: survey results reveal
widespread use, but optimization is challenging.
April 18, 2018
ISMP Medication Safety Alert! Acute Care Edition. April 5, 2018;23:1-5.
https://psnet.ahrq.gov/issue/smart-pumps-practice-survey-results-reveal-widespread-use-optimization-
challenging
Smart pumps are co…