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  1. psnet.ahrq.gov/issue/tallman-lettering-strategy-differentiation-look-alike-sound-alike-drug-names-role-familiarity
    May 27, 2020 - Study Tallman lettering as a strategy for differentiation in look-alike, sound-alike drug names: the role of familiarity in differentiating drug doppelgangers. Citation Text: DeHenau C, Becker MW, Bello NM, et al. Tallman lettering as a strategy for differentiation in look-alike, sound-a…
  2. psnet.ahrq.gov/issue/national-aeronautics-and-space-administration-threat-and-error-model-applied-pediatric
    March 07, 2018 - Study National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths. Citation Text: Hickey EJ, Nosikova Y, Pham-Hung E, et al. National Aeronautics and Space Administration "threat and error" model…
  3. psnet.ahrq.gov/issue/identification-common-themes-never-events-data-published-nhs-england
    April 07, 2021 - Study Identification of common themes from never events data published by NHS England. Citation Text: Omar I, Graham Y, Singhal R, et al. Identification of common themes from never events data published by NHS England. World J Surg. 2021;45(3):697-704. doi:10.1007/s00268-020-05867-7. C…
  4. psnet.ahrq.gov/issue/wrong-site-surgery-retained-surgical-items-and-surgical-fires-systematic-review-surgical
    March 13, 2013 - Review Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. Citation Text: Hempel S, Maggard-Gibbons M, Nguyen DK, et al. Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires : A Systematic Review of Surgical Never Even…
  5. psnet.ahrq.gov/issue/interventions-reduce-medication-dispensing-administration-and-monitoring-errors-pediatric
    June 23, 2021 - Review Interventions to reduce medication dispensing, administration, and monitoring errors in pediatric professional healthcare settings: a systematic review. Citation Text: Koeck JA, Young NJ, Kontny U, et al. Interventions to reduce medication dispensing, administration, and monitorin…
  6. psnet.ahrq.gov/issue/anticipating-patient-safety-events-psychiatric-care
    March 10, 2021 - Study Anticipating patient safety events in psychiatric care. Citation Text: Yerstein MC, SUNDARARAJ DEEPIKA, McClean M, et al. Anticipating patient safety events in psychiatric care. J Psychiatr Pract. 2024;30(1):68-72. doi:10.1097/pra.0000000000000760. Copy Citation Format: …
  7. psnet.ahrq.gov/issue/impact-team-performance-surgical-safety-checklist-patient-outcomes-operating-room-black-box
    March 20, 2024 - Study Impact of team performance on the surgical safety checklist on patient outcomes: an operating room black box analysis. Citation Text: Al Abbas AI, Meier J, Daniel W, et al. Impact of team performance on the surgical safety checklist on patient outcomes: an operating room black box …
  8. www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/intro.html
    September 01, 2015 - Preventing CAUTI in the ICU Setting: Facilitator’s Guide Introduction Previous Page Next Page Table of Contents Preventing CAUTI in the ICU Setting: Facilitator’s Guide Introduction Module 1: Overview Module 2: Urinary Catheter Maintenance Module 3: Conversations Around Device Necessity Mo…
  9. www.ahrq.gov/hai/cauti-tools/archived-webinars/patient-family-engagement-ed-slides.html
    December 01, 2017 - Patient and Family Engagement in the Emergency Department Slide Presentation Slide 1 Patient and Family Engagement in the ED Sue Collier, RN, MSN, FABC Clinical Content Development Lead Health Research & Education Trust American Hospital Association Image: Photo of Sue Collier, RN. Slide 2 Le…
  10. psnet.ahrq.gov/issue/strategies-prevent-central-line-associated-bloodstream-infections-acute-care-hospitals-2022
    February 07, 2022 - Organizational Policy/Guidelines Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. Citation Text: Buetti N, Marschall J, Drees M, et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: …
  11. psnet.ahrq.gov/issue/intravenous-smart-pumps-point-care-descriptive-observational-study
    February 24, 2021 - Study Intravenous smart pumps at the point of care: a descriptive, observational study. Citation Text: Giuliano KK, Blake JWC, Bittner NP, et al. Intravenous smart pumps at the point of care: a descriptive, observational study. J Patient Saf. 2022;18(6):553-558. doi:10.1097/pts.000000000…
  12. www.uspreventiveservicestaskforce.org/home/getfilebytoken/_CqYnP2r9XUSuDgkPpF9y8
    May 01, 2025 - Summary of USPSTF Final Recommendation: Screening for Syphilis Infection During Pregnancy Clinicians Summary of USPSTF Final Recommendation Screening for Syphilis Infection During Pregnancy May 2025 What does the USPSTF recommend? A Grade For pregnant women: Provi…
  13. psnet.ahrq.gov/issue/veterans-health-administration-response-covid-19-crisis-surveillance-action
    November 17, 2021 - Commentary Veterans Health Administration response to the COVID-19 crisis: surveillance to action. Citation Text: Charles MA, Yackel EE, Mills PD, et al. Veterans Health Administration response to the COVID-19 crisis: surveillance to action. J Patient Saf. 2022;18(7):686-691. doi:10.1097…
  14. www.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
    April 01, 2025 - Quality and Safety Review System (QSRS) Retrospectively Reviewing Inpatient Health Records To Identify Adverse Events Medical errors are an ongoing challenge to the healthcare system in the United States. The extent of medical errors in U.S. hospitals was revealed in 2000 when the Institute of Medicine (now the…
  15. psnet.ahrq.gov/issue/safety-surgical-telehealth-outpatient-and-inpatient-setting
    September 13, 2023 - Review Safety of surgical telehealth in the outpatient and inpatient setting. Citation Text: Purnell S, Zheng F. Safety of Surgical Telehealth in the Outpatient and Inpatient Setting. Surg Clin North Am. 2020;101(1):109-119. doi:10.1016/j.suc.2020.09.003. Copy Citation Format: …
  16. www.uspreventiveservicestaskforce.org/home/getfilebytoken/Xm5_jgUrXXGAJe8WJh_9KK
    June 01, 2024 - Summary of USPSTF Final Recommendation: Interventions to Prevent Falls in Community-Dwelling Older Adults Clinicians Summary of USPSTF Final Recommendation Interventions to Prevent Falls in Community-Dwelling Older Adults June 2024 What does the USPSTF recommend? B Grade …
  17. psnet.ahrq.gov/issue/patient-safety-when-receiving-telephone-advice-primary-care-swedish-qualitative-interview
    October 13, 2021 - Study Patient safety when receiving telephone advice in primary care - a Swedish qualitative interview study. Citation Text: Berntsson K, Eliasson M, Beckman L. Patient safety when receiving telephone advice in primary care – a Swedish qualitative interview study. BMC Nurs. 2022;21(1):24…
  18. digital.ahrq.gov/program-overview/research-stories/clinical-decision-support-tool-preventing-falls
    January 01, 2023 - A Clinical Decision Support Tool for Preventing Falls Theme: Optimizing Care Delivery for Clinicians Subtheme: Scaling Effective and Interoperable CDS to Improve Care and Decision Making Tools like ASPIRE that integrate fall prevention clinical decision support and patient resources may be…
  19. psnet.ahrq.gov/issue/engaging-patients-vigilant-partners-safety-systematic-review
    February 06, 2019 - Review Classic Engaging patients as vigilant partners in safety: a systematic review. Citation Text: Schwappach DLB. Engaging patients as vigilant partners in safety: a systematic review. Med Care Res Rev. 2010;67(2):119-148. doi:10.1177/1077558709342254. Co…
  20. psnet.ahrq.gov/issue/engaging-patient-observer-promote-hand-hygiene-compliance-ambulatory-care
    September 02, 2020 - Study Engaging the patient as observer to promote hand hygiene compliance in ambulatory care. Citation Text: Bittle MJ, LaMarche S. Engaging the patient as observer to promote hand hygiene compliance in ambulatory care. Jt Comm J Qual Patient Saf. 2009;35(10):519-25. Copy Citation …