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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60359/psn-pdfMay 20, 2020 - Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. May 20, 2020 ISMP Medication Safety Alert! Acute care edition. May 7, 2020;25(9). https://psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone- overdose Lack of familiarity with sm… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72569/psn-pdfJanuary 01, 2021 - Risk factors associated with medication ordering errors. December 16, 2020 Abraham J, Galanter WL, Touchette DR, et al. Risk factors associated with medication ordering errors. J Am Med Inform Assoc. 2021;18(1):86-94. doi:10.1093/jamia/ocaa264. https://psnet.ahrq.gov/issue/risk-factors-associated-medication-orderin… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47400/psn-pdfNovember 28, 2018 - Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. November 28, 2018 Müller M, Jürgens J, Redaèlli M, et al. Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ Open. 2018;8(8):e022202. doi:10.1136/bmjopen-2018-022202… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41606/psn-pdfFebruary 01, 2019 - Safe use of opioids in hospitals. December 23, 2016 Sentinel Event Alert. 2012;49:1-5. https://psnet.ahrq.gov/issue/safe-use-opioids-hospitals Opioid pain medications are considered high-risk medications due to the potential for respiratory depression and other adverse effects. Because these medications are freque… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60280/psn-pdfApril 29, 2020 - Missed, rationed or unfinished nursing care: a scoping review of patient outcomes. April 29, 2020 Kalánková D, Kirwan M, Bartoní?ková D, et al. Missed, rationed or unfinished nursing care: A scoping review of patient outcomes. J Nurs Manag. 2020;28(8):1783-1797. doi:10.1111/jonm.12978. https://psnet.ahrq.gov/issue… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836776/psn-pdfMarch 23, 2022 - Potentially inappropriate medications and their effect on falls during hospital admission. March 23, 2022 Damoiseaux-Volman BA, Raven K, Sent D, et al. Potentially inappropriate medications and their effect on falls during hospital admission. Age Ageing. 2022;51(1):afab205. doi:10.1093/ageing/afab205. https://psne… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/839315/psn-pdfJanuary 01, 2024 - Six major steps to make investigations of suicide valuable for learning and prevention. November 2, 2022 Fröding E, Vincent C, Andersson-Gäre B, et al. Six major steps to make investigations of suicide valuable for learning and prevention. Arch Suicide Res. 2024;28(1):1-19. doi:10.1080/13811118.2022.2133652. https… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39975/psn-pdfMarch 03, 2011 - Communication failure in the operating room. March 3, 2011 Halverson AL, Casey JT, Andersson J, et al. Communication failure in the operating room. Surgery. 2011;149(3):305-310. doi:10.1016/j.surg.2010.07.051. https://psnet.ahrq.gov/issue/communication-failure-operating-room Communication failures are a well-chara… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/865583/psn-pdfApril 17, 2024 - Impact of repeated reimbursement penalties on hospital total quality scores. April 17, 2024 Brewer A, Hughes MC, Patel KN. Impact of repeated reimbursement penalties on hospital total quality scores. J Patient Saf. 2024;20(3):198-201. doi:10.1097/pts.0000000000001199. https://psnet.ahrq.gov/issue/impact-repeated-r… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45449/psn-pdfOctober 29, 2017 - Situational awareness—what it means for clinicians, its recognition and importance in patient safety. October 29, 2017 Green B, Parry D, Oeppen RS, et al. Situational awareness - what it means for clinicians, its recognition and importance in patient safety. Oral Dis. 2017;23(6):721-725. doi:10.1111/odi.12547. htt… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44898/psn-pdfNovember 23, 2016 - Types and patterns of safety concerns in home care: client and family caregiver perspectives. November 23, 2016 Tong CE, Sims-Gould J, Martin-Matthews A. Types and patterns of safety concerns in home care: client and family caregiver perspectives. Int J Qual Health Care. 2016;28(2):214-220. doi:10.1093/intqhc/mzw0… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/844780/psn-pdfSeptember 11, 2019 - Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety. September 11, 2019 Kaba A, Barnes S. Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety. Adv Simul (Lond). 2019;4:1… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43500/psn-pdfNovember 17, 2014 - A systematic review of behavioural marker systems in healthcare: what do we know about their attributes, validity and application? November 17, 2014 Dietz AS, Pronovost P, Benson KN, et al. A systematic review of behavioural marker systems in healthcare: what do we know about their attributes, validity and applica… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/854255/psn-pdfOctober 04, 2023 - Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival. October 4, 2023 McCoy C, Keshvani N, Warsi M, et al. Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival. BMJ Open Qual. 2023;12(3):e002220. doi:10.11… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47975/psn-pdfMay 29, 2019 - Surgical Innovation, New Techniques and Technologies: A Guide to Good Practice. May 29, 2019 London, UK: Royal College of Surgeons of England; 2019. https://psnet.ahrq.gov/issue/surgical-innovation-new-techniques-and-technologies-guide-good-practice Introducing innovations in practice involves taking calculated ri… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866955/psn-pdfOctober 16, 2024 - Adverse diagnostic events in hospitalised patients: a single-centre, retrospective cohort study. October 16, 2024 Dalal AK, Plombon S, Konieczny K, et al. Adverse diagnostic events in hospitalised patients: a single- centre, retrospective cohort study. BMJ Qual Saf. 2024;Epub Oct 1. doi:10.1136/bmjqs-2024-017183. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46002/psn-pdfOctober 13, 2018 - Exploring physician perspectives of residency holdover handoffs: a qualitative study to understand an increasingly important type of handoff. October 13, 2018 Duong JA, Jensen TP, Morduchowicz S, et al. Exploring Physician Perspectives of Residency Holdover Handoffs: A Qualitative Study to Understand an Increasing… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45848/psn-pdfNovember 19, 2018 - New Horizons in Patient Safety: Understanding Communication: Case Studies for Physicians. November 19, 2018 Hannawa AF, Wu AW, Juhasz RS, eds. Berlin, Germany: DeGruyter; 2017. ISBN: 9783110455014. https://psnet.ahrq.gov/issue/new-horizons-patient-safety-understanding-communication-case-studies- physicians Poor c… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36118/psn-pdfSeptember 24, 2010 - Implementing patient safety practices in small ambulatory care settings. September 24, 2010 Schauberger CW, Larson P. Implementing patient safety practices in small ambulatory care settings. Jt Comm J Qual Patient Saf. 2006;32(8):419-425. https://psnet.ahrq.gov/issue/implementing-patient-safety-practices-small-amb… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72600/psn-pdfDecember 23, 2020 - Improving hospital safety culture for falls prevention through interdisciplinary health education. December 23, 2020 Lopez-Jeng C, Eberth SD. Improving hospital safety culture for falls prevention through interdisciplinary health education. Health Promot Pract. 2020;21(6):918-925. doi:10.1177/1524839919840337. htt…
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