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  1. psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx Spotlight A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion Source and Credits • This presentation is based on the July 2023 AHRQ WebM&M Spotlight Case o See the full article at ht…
  2. psnet.ahrq.gov/perspective/ems-patient-safety-field
    July 28, 2021 - ems-protocols-all-paramedics-should-follow-7c1zyNEC6v1SjDQM/#:~:text=The%20purpose%20of%20EMS%20protocols,assessing
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837744/psn-pdf
    July 27, 2022 - Medication orders with future start dates: how far away is too far? July 27, 2022 ISMP Medication Safety Alert! Acute care edition. July 14, 2022:27(14):1-4. https://psnet.ahrq.gov/issue/medication-orders-future-start-dates-how-far-away-too-far Human errors that occur while interacting with electronic health recor…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867049/psn-pdf
    October 30, 2024 - National Review of Maternity Services in England 2022 to 2024. October 30, 2024 National Review Of Maternity Services In England 2022 To 2024. Newcastle Upon Tyne, UK: Care Quality Commission; September 2024. https://psnet.ahrq.gov/issue/national-review-maternity-services-england-2022-2024 Maternal safety is a gl…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35127/psn-pdf
    February 24, 2011 - Beyond the medical record: other modes of error acknowledgment. February 24, 2011 Rosenthal M, Cornett PL, Sutcliffe K, et al. Beyond the medical record: other modes of error acknowledgment. J Gen Intern Med. 2005;20(5):404-9. https://psnet.ahrq.gov/issue/beyond-medical-record-other-modes-error-acknowledgment Thi…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45275/psn-pdf
    November 01, 2017 - Electronic tools to support medication reconciliation—a systematic review. November 1, 2017 Marien S, Krug B, Spinewine A. Electronic tools to support medication reconciliation: a systematic review. J Am Med Inform Assoc. 2017;24(1):227-240. doi:10.1093/jamia/ocw068. https://psnet.ahrq.gov/issue/electronic-tools-s…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46298/psn-pdf
    October 18, 2017 - CVS taps a design legend to reinvent the prescription label. Next stop: the pharmacy. October 18, 2017 Kuang C. Fast Company. October 4, 2017. https://psnet.ahrq.gov/issue/cvs-taps-design-legend-reinvent-prescription-label-next-stop-pharmacy Complicated systems often require more than one change to improve their s…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46711/psn-pdf
    July 01, 2019 - The STOP Measure. Safe and Transparent Opioid Prescribing to Promote Patient Safety and Reduced Risk of Opioid Misuse. July 1, 2019 Washington, DC: America's Health Insurance Plans; 2019. https://psnet.ahrq.gov/issue/stop-measure-safe-and-transparent-opioid-prescribing-promote-patient-safety- and-reduced-risk Gu…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47758/psn-pdf
    April 17, 2019 - Contribution of adverse events to death of hospitalised patients. April 17, 2019 Haukland EC, Mevik K, von Plessen C, et al. Contribution of adverse events to death of hospitalised patients. BMJ Open Qual. 2019;8(1):e000377. doi:10.1136/bmjoq-2018-000377. https://psnet.ahrq.gov/issue/contribution-adverse-events-de…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35402/psn-pdf
    September 10, 2009 - Can patients be part of the solution? Views on their role in preventing medical errors. September 10, 2009 Hibbard JH, Peters E, Slovic P, et al. Can patients be part of the solution? Views on their role in preventing medical errors. Med Care Res Rev. 2005;62(5):601-16. https://psnet.ahrq.gov/issue/can-patients-be…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44785/psn-pdf
    January 27, 2016 - Reducing Adverse Drug Events Related to Opioids Implementation Guide. January 27, 2016 Frederickson TW. Gordon DB, De Pinto M, et al. Philadelphia, PA: Society of Hospital Medicine; 2015. https://psnet.ahrq.gov/issue/reducing-adverse-drug-events-related-opioids-implementation-guide Opioids are high-risk medication…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40097/psn-pdf
    January 19, 2011 - Use of an electronic information system to identify adverse events resulting in an emergency department visit. January 19, 2011 Ackroyd-Stolarz S, MacKinnon NJ, Zed PJ, et al. Use of an electronic information system to identify adverse events resulting in an emergency department visit. Qual Saf Health Care. 2010;1…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47213/psn-pdf
    June 20, 2018 - Are second victims getting the help they need? June 20, 2018 Headley M. Patient Saf Qual Healthc. May/June 2018. https://psnet.ahrq.gov/issue/are-second-victims-getting-help-they-need Clinicians can experience emotional stress, guilt, and insecurity after making a mistake. Organizations are increasingly building p…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50653/psn-pdf
    November 13, 2019 - A national patient safety curriculum in pediatric emergency medicine. November 13, 2019 Stankovic C, Wolff M, Chang TP, et al. A National Patient Safety Curriculum in Pediatric Emergency Medicine. Pediatr Emerg Care. 2019;35(8):519-521. doi:10.1097/PEC.0000000000001533. https://psnet.ahrq.gov/issue/national-patien…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46278/psn-pdf
    July 19, 2017 - The opioid epidemic: what can surgeons do about it? July 19, 2017 Saluja S, Selzer D, Meara JG, et al. Bull Am Coll Surg. 2017;102(7):13-18. https://psnet.ahrq.gov/issue/opioid-epidemic-what-can-surgeons-do-about-it Surgeons often prescribe opioids for patients after procedures, so they are in a key position to ass…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50445/psn-pdf
    October 09, 2019 - A demonstration project on the impact of safety culture on infection control practices in hemodialysis October 9, 2019 Millson T, Hackbarth D, Bernard HL. A demonstration project on the impact of safety culture on infection control practices in hemodialysis. Am J Infect Control. 2019;47(9):1122-1129. doi:10.1016/j…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60020/psn-pdf
    March 04, 2020 - The eNOTSS platform for surgeons’ nontechnical skills performance improvement. March 4, 2020 Pradarelli JC, Yule S, Smink DS. The eNOTSS Platform for Surgeons’ Nontechnical Skills Performance Improvement. JAMA Surg. 2020;155(5):438-439. doi:10.1001/jamasurg.2019.5880. https://psnet.ahrq.gov/issue/enotss-platform-s…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46025/psn-pdf
    July 11, 2017 - Measuring to improve medication reconciliation in a large subspecialty outpatient practice. July 11, 2017 Kern E, Dingae MB, Langmack EL, et al. Measuring to Improve Medication Reconciliation in a Large Subspecialty Outpatient Practice. Jt Comm J Qual Patient Saf. 2017;43(5):212-223. doi:10.1016/j.jcjq.2017.02.005…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60764/psn-pdf
    August 05, 2020 - As coronavirus ravaged nursing homes, inspectors were not being tested. August 5, 2020 Dolan J, Mejia B. As coronavirus ravaged nursing homes, inspectors were not being tested. Los Angeles Times. 2020;July 24. https://psnet.ahrq.gov/issue/coronavirus-ravaged-nursing-homes-inspectors-were-not-being-tested Worker s…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45263/psn-pdf
    September 04, 2016 - PSYCH: a mnemonic to help psychiatric residents decrease patient handoff communication errors. September 4, 2016 Mariano MT, Brooks V, DiGiacomo M. PSYCH: A Mnemonic to Help Psychiatric Residents Decrease Patient Handoff Communication Errors. Jt Comm J Qual Patient Saf. 2016;42(7):316-320. https://psnet.ahrq.gov/i…

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