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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47268/psn-pdf
    May 11, 2019 - Measuring shared mental models in healthcare. May 11, 2019 Gisick LM, Webster KL, Keebler JR, et al. J Patient Saf Risk Manag. 2018;23:207–219. https://psnet.ahrq.gov/issue/measuring-shared-mental-models-healthcare Shared mental models are an important element of team collaboration. This review explores the current…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837430/psn-pdf
    June 15, 2022 - Stop using these adult bed rails, warns the Consumer Product Safety Commission. June 15, 2022 Treisman R. National Public Radio. June 6, 2022 https://psnet.ahrq.gov/issue/stop-using-these-adult-bed-rails-warns-consumer-product-safety-commission Bedrails are used in hospitals and at home to minimize falls despite t…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35109/psn-pdf
    November 03, 2015 - Evaluation of the implementation of the alert issued by the UK National Patient Safety Agency on the storage and handling of potassium chloride concentrate solution. November 3, 2015 Lankshear AJ, Sheldon TA, Lowson K, et al. Evaluation of the implementation of the alert issued by the UK National Patient Safety Ag…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73869/psn-pdf
    October 21, 2021 - Disrespectful behavior in healthcare: has it improved? Please take our survey! October 21, 2021 ISMP Medication Safety Alert! Acute care edition. September 9, 2021;26(18);1-5. https://psnet.ahrq.gov/issue/disrespectful-behavior-healthcare-has-it-improved-please-take-our-survey Disrespectful behavior is a persisten…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837604/psn-pdf
    June 29, 2022 - Diagnostic overshadowing among groups experiencing health disparities. June 29, 2022 Sentinel Event Alert. June 22, 2022;(65):1-7. https://psnet.ahrq.gov/issue/diagnostic-overshadowing-among-groups-experiencing-health-disparities A clinician's knowledge of an existing condition can implicitly affect treatment reco…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50600/psn-pdf
    October 30, 2019 - HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. October 30, 2019 HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. Washington DC: US Department of Health and Human Services. October 2019. …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838015/psn-pdf
    September 07, 2022 - Physicians and cognitive decline: a challenge for state medical boards. September 7, 2022 Hoffman S. Physicians and cognitive decline: a challenge for state medical boards. J Med Regulation. 2022;108(2):19-28. doi:10.30770/2572-1852-108.2.19. https://psnet.ahrq.gov/issue/physicians-and-cognitive-decline-challenge-…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45492/psn-pdf
    September 28, 2016 - Understanding human over-reliance on technology. September 28, 2016 ISMP Medication Safety Alert! Acute Care Edition. September 8, 2016;21:1-4. https://psnet.ahrq.gov/issue/understanding-human-over-reliance-technology Over-reliance on technology can contribute to error due to user complacency. Reviewing how the ten…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43874/psn-pdf
    February 25, 2015 - An overview of the use and implementation of checklists in surgical specialities - a systematic review. February 25, 2015 Patel J, Ahmed K, Guru KA, et al. An overview of the use and implementation of checklists in surgical specialities - a systematic review. Int J Surg. 2014;12(12):1317-23. doi:10.1016/j.ijsu.2014…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837346/psn-pdf
    June 08, 2022 - Decontamination of Surgical Instruments. June 8, 2022 Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022. https://psnet.ahrq.gov/issue/decontamination-surgical-instruments Surgical equipment sterilization can be hampered by equipment design, production pressures, process complexity and policy mi…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42564/psn-pdf
    September 11, 2013 - Error rating tool to identify and analyse technical errors and events in laparoscopic surgery. September 11, 2013 Bonrath EM, Zevin B, Dedy NJ, et al. Error rating tool to identify and analyse technical errors and events in laparoscopic surgery. Br J Surg. 2013;100(8):1080-8. doi:10.1002/bjs.9168. https://psnet.ah…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45789/psn-pdf
    January 11, 2017 - Concurrent and Overlapping Surgeries: Additional Measures Warranted. January 11, 2017 US Senate Finance Committee. December 6, 2016. https://psnet.ahrq.gov/issue/concurrent-and-overlapping-surgeries-additional-measures-warranted The practice of scheduling concurrent surgeries has raised concerns about increased ri…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47955/psn-pdf
    April 17, 2019 - Will human factors restore faith in the GMC? April 17, 2019 Morgan L, Benson D, McCulloch P. Will human factors restore faith in the GMC? BMJ. 2019;364:l1037. doi:10.1136/bmj.l1037. https://psnet.ahrq.gov/issue/will-human-factors-restore-faith-gmc Investigations into medical mistakes that result in patient harm sh…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50822/psn-pdf
    January 22, 2020 - Nurses' sleep, work hours, and patient care quality, and safety January 22, 2020 Stimpfel AW, Fatehi F, Kovner C. Sleep Health. 2020;6(3):314-320. https://psnet.ahrq.gov/issue/nurses-sleep-work-hours-and-patient-care-quality-and-safety Research provides evidence that sleep deprivation among nurses is a threat to p…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46746/psn-pdf
    March 07, 2018 - Safety with nebulized medications requires an interdisciplinary team approach. March 7, 2018 ISMP Medication Safety Alert! Acute care edition. February 22, 2018;23(4):1-5. https://psnet.ahrq.gov/issue/safety-nebulized-medications-requires-interdisciplinary-team-approach Myriad system and clinician failures can con…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36691/psn-pdf
    January 18, 2011 - The burden and risk factors for adverse drug events in older patients--a prospective cross-sectional study. January 18, 2011 Tipping B, Kalula S, Badri M. The burden and risk factors for adverse drug events in older patients--a prospective cross-sectional study. S Afr Med J. 2006;96(12):1255-1259. https://psnet.ah…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50729/psn-pdf
    December 11, 2019 - Improving Diagnostic Quality & Safety/Reducing Diagnostic Error: Measurement Considerations. December 11, 2019 Washington DC; National Quality Forum: October 28, 2019. https://psnet.ahrq.gov/issue/improving-diagnostic-quality-safetyreducing-diagnostic-error-measurement- considerations Efforts to track, understand…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37225/psn-pdf
    December 15, 2011 - Development of an instrument to measure seniors' patient safety health beliefs: the Seniors Empowerment and Advocacy in Patient Safety (SEAPS) survey. December 15, 2011 Elder NC, Regan SL, Pallerla H, et al. Development of an instrument to measure seniors’ patient safety health beliefs: The Seniors Empowerment and…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74076/psn-pdf
    November 17, 2021 - Influence of perioperative handoffs on complications and outcomes. November 17, 2021 Burden AR, Potestio C, Pukenas E. Influence of perioperative handoffs on complications and outcomes. Adv Anesth. 2021;39:133-148. doi:10.1016/j.aan.2021.07.008. https://psnet.ahrq.gov/issue/influence-perioperative-handoffs-complic…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/858173/psn-pdf
    December 13, 2023 - Measurement of ambulatory medication errors in children: a scoping review. December 13, 2023 Rickey L, Auger K, Britto MT, et al. Measurement of ambulatory medication errors in children: a scoping review. Pediatrics. 2023;152(6):e2023061281. doi:10.1542/peds.2023-061281. https://psnet.ahrq.gov/issue/measurement-am…
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