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psnet.ahrq.gov/node/44687/psn-pdf
June 21, 2016 - Free From Harm: Accelerating Patient Safety
Improvement Fifteen Years After To Err Is Human.
June 21, 2016
Boston, MA: National Patient Safety Foundation; 2015.
https://psnet.ahrq.gov/issue/free-harm-accelerating-patient-safety-improvement-fifteen-years-after-err-
human
This report provides an objective assessmen…
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psnet.ahrq.gov/issue/neuromuscular-blocking-agents-reducing-associated-wrong-drug-errors
April 26, 2023 - Newspaper/Magazine Article
Neuromuscular blocking agents: reducing associated wrong-drug errors.
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April 16, 2018
This article discu…
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psnet.ahrq.gov/node/47661/psn-pdf
January 23, 2019 - Safety enhancements every hospital must consider in
wake of another tragic neuromuscular blocker event.
January 23, 2019
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24:1-6.
https://psnet.ahrq.gov/issue/safety-enhancements-every-hospital-must-consider-wake-another-tragic-
neuromuscular-blocke…
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psnet.ahrq.gov/node/867640/psn-pdf
February 26, 2025 - Patient safety of virtual primary care: a qualitative study
examining risks and mitigation strategies.
February 26, 2025
Lounsbury O, Li E, Lunova T, et al. Patient safety of virtual primary care: a qualitative study examining risks
and mitigation strategies. Health Policy Tech. 2025;14(1):100966. doi:10.1016/j.hlp…
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psnet.ahrq.gov/issue/when-doctor-too-old-job
March 04, 2020 - Newspaper/Magazine Article
When is a doctor too old for the job?
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September 18, 2019
Potential deterioration of an aging surgeon's…
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digital.ahrq.gov/cpt
January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…
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psnet.ahrq.gov/node/47225/psn-pdf
November 02, 2018 - Preventable adverse drug events among inpatients: a
systematic review.
November 2, 2018
Gates PJ, Meyerson SA, Baysari M, et al. Preventable Adverse Drug Events Among Inpatients: A
Systematic Review. Pediatrics. 2018;142(3):e20180805. doi:10.1542/peds.2018-0805.
https://psnet.ahrq.gov/issue/preventable-adverse-dru…
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psnet.ahrq.gov/node/43594/psn-pdf
May 01, 2015 - Impact of introducing an electronic physiological
surveillance system on hospital mortality.
May 1, 2015
Schmidt PE, Meredith P, Prytherch DR, et al. Impact of introducing an electronic physiological surveillance
system on hospital mortality. BMJ Qual Saf. 2015;24(1):10-20. doi:10.1136/bmjqs-2014-003073.
https://p…
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psnet.ahrq.gov/node/46200/psn-pdf
August 30, 2017 - Clinical practice guideline: safe medication use in the
ICU.
August 30, 2017
Kane-Gill SL, Dasta JF, Buckley MS, et al. Clinical Practice Guideline: Safe Medication Use in the ICU. Crit
Care Med. 2017;45(9):e877-e915. doi:10.1097/CCM.0000000000002533.
https://psnet.ahrq.gov/issue/clinical-practice-guideline-safe-m…
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psnet.ahrq.gov/node/41496/psn-pdf
December 21, 2014 - Hospital-based medication reconciliation practices: a
systematic review.
December 21, 2014
Mueller SK, Sponsler KC, Kripalani S, et al. Hospital-based medication reconciliation practices: a
systematic review. Arch Intern Med. 2012;172(14):1057-69. doi:10.1001/archinternmed.2012.2246.
https://psnet.ahrq.gov/issue/h…
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psnet.ahrq.gov/issue/shakespeare-was-target-dont-be-borrower-or-lender
May 11, 2022 - Newspaper/Magazine Article
Shakespeare was on target—don't be a borrower or lender.
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June 10, 2018
This piece describes the dangers…
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www.ahrq.gov/data/data-visualization/index.html?page=0
September 01, 2023 - Data Visualizations
AHRQ's interactive data visualization tools allow researchers, policymakers, healthcare leaders, and others to view visual depictions of healthcare trends. Based on content from AHRQ's data resources, the visualizations address various topics, such as COVID-19 hospitalizations, health insura…
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psnet.ahrq.gov/node/838251/psn-pdf
October 05, 2022 - Serious hazards of transfusion: evaluating the dangers of
a wrong patient autologous salvaged blood in cardiac
surgery.
October 5, 2022
Uramatsu M, Maeda H, Mishima S, et al. Serious hazards of transfusion: evaluating the dangers of a wrong
patient autologous salvaged blood in cardiac surgery. J Cardiothorac Surg.…
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psnet.ahrq.gov/node/36163/psn-pdf
September 29, 2010 - Improving the bar-coded medication administration
system at the Department of Veterans Affairs.
September 29, 2010
Mills PD, Neily J, Mims E, et al. Improving the bar-coded medication administration system at the
Department of Veterans Affairs. Am J Health Syst Pharm. 2006;63(15):1442-7.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/38175/psn-pdf
April 11, 2011 - An intervention to decrease narcotic-related adverse drug
events in children's hospitals.
April 11, 2011
Sharek PJ, McClead RE, Taketomo C, et al. An intervention to decrease narcotic-related adverse drug
events in children's hospitals. Pediatrics. 2008;122(4):e861-e866. doi:10.1542/peds.2008-1011.
https://psnet.a…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/putoolkit_module1_tools.docx
March 01, 2013 - Pressure Ulcer Prevention Toolkit
Pressure Ulcer Prevention Toolkit
Module 1 Tools
1E: Resource Needs Assessment (Revised)
Sullivan N. Chapter 21. Preventing in-facility pressure ulcers. In: Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. March 2013. Agency for …
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psnet.ahrq.gov/node/73197/psn-pdf
April 28, 2021 - Medical Office Survey: 2020 User Database Report.
April 28, 2021
Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety CultureTM (SOPSTM). Rockville,
MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0034.
https://psnet.ahrq.gov/issue/medical-office-survey-2020-user…
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psnet.ahrq.gov/node/38217/psn-pdf
April 26, 2017 - Patient safety climate in US hospitals: variation by
management level.
April 26, 2017
Singer SJ, Falwell A, Gaba DM, et al. Patient safety climate in US hospitals: variation by management
level. Med Care. 2008;46(11):1149-56. doi:10.1097/MLR.0b013e31817925c1.
https://psnet.ahrq.gov/issue/patient-safety-climate-us-…
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psnet.ahrq.gov/node/47303/psn-pdf
March 18, 2019 - Transforming concepts in patient safety: a progress
report.
March 18, 2019
Gandhi TK, Kaplan GS, Leape L, et al. Transforming concepts in patient safety: a progress report. BMJ
Qual Saf. 2018;27(12):1019-1026. doi:10.1136/bmjqs-2017-007756.
https://psnet.ahrq.gov/issue/transforming-concepts-patient-safety-progress…
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psnet.ahrq.gov/node/60934/psn-pdf
September 23, 2020 - Hospital ward adaptation during the COVID-19 pandemic:
a national survey of academic medical centers.
September 23, 2020
Auerbach AD, O'Leary KJ, Greysen SR, et al. Hospital ward adaptation during the COVID-19 pandemic: a
national survey of academic medical centers. J Hosp Med. 2020;15(8):483-488. doi:10.12788/jhm.…