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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40206/psn-pdf
    June 15, 2011 - Frequency of pediatric medication administration errors and contributing factors. June 15, 2011 Ozkan S, Kocaman G, Ozturk C, et al. Frequency of pediatric medication administration errors and contributing factors. J Nurs Care Qual. 2011;26(2):136-43. doi:10.1097/NCQ.0b013e3182031006. https://psnet.ahrq.gov/issue/…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43825/psn-pdf
    January 28, 2015 - A systematic review of adult admissions to ICUs related to adverse drug events. January 28, 2015 Jolivot P-A, Hindlet P, Pichereau C, et al. A systematic review of adult admissions to ICUs related to adverse drug events. Crit Care. 2014;18(6):643. doi:10.1186/s13054-014-0643-5. https://psnet.ahrq.gov/issue/systema…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40730/psn-pdf
    August 27, 2012 - Analysis of risk of medical errors using structural- equation modelling: a 6-month prospective cohort study. August 27, 2012 Tanaka M, Tanaka K, Takano T, et al. Analysis of risk of medical errors using structural-equation modelling: a 6-month prospective cohort study. BMJ Qual Saf. 2012;21(9):784-790. doi:10.1136/…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74276/psn-pdf
    January 19, 2022 - Guideline for Prevention of Unintentionally Retained Surgical Items. January 19, 2022 Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6. doi:10.1002/aorn.13579. https://psnet.ahrq.gov/issue/guideline-prevention-unintentionally-retained-surgical-items Retained su…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37598/psn-pdf
    March 12, 2008 - Patient safety in trauma: maximal impact management errors at a level I trauma center. March 12, 2008 Ivatury RR, Guilford K, Malhotra AK, et al. Patient safety in trauma: maximal impact management errors at a level I trauma center. J Trauma. 2008;64(2):265-270; discussion 270-272. doi:10.1097/TA.0b013e318163359d.…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74188/psn-pdf
    December 15, 2021 - Semantically ambiguous language in the teaching operating room. December 15, 2021 Liu C, McKenzie A, Sutkin G. Semantically ambiguous language in the teaching operating room. J Surg Edu. 2021;78(6):1938-1947. doi:10.1016/j.jsurg.2021.03.020. https://psnet.ahrq.gov/issue/semantically-ambiguous-language-teaching-ope…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42049/psn-pdf
    February 20, 2013 - Mitigating error vulnerability at the transition of care through the use of health IT applications. February 20, 2013 Cortelyou-Ward K, Swain A, Yeung T. Mitigating Error Vulnerability at the Transition of Care through the Use of Health IT Applications. J Med Syst. 2012;36(6). doi:10.1007/s10916-012-9855-x. https:…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34922/psn-pdf
    February 25, 2009 - Potential errors and their prevention in operating room teamwork as experienced by Finnish, British and American nurses. February 25, 2009 Silén-Lipponen M, Tossavainen K, Turunen H, et al. Potential errors and their prevention in operating room teamwork as experienced by Finnish, British and American nurses. Int …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43961/psn-pdf
    August 02, 2015 - Reducing inappropriate polypharmacy: the process of deprescribing. August 2, 2015 Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-34. doi:10.1001/jamainternmed.2015.0324. https://psnet.ahrq.gov/issue/reducing-inappropriate-pol…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43033/psn-pdf
    March 12, 2014 - Current challenges and future perspectives for patient safety in surgery. March 12, 2014 Stahel PF, Mauffrey C, Butler N. Current challenges and future perspectives for patient safety in surgery. Patient Saf Surg. 2014;8(1):9. doi:10.1186/1754-9493-8-9. https://psnet.ahrq.gov/issue/current-challenges-and-future-pe…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43218/psn-pdf
    July 28, 2014 - Risk management—learning from the mistakes of others. July 28, 2014 Meydan C. Risk management--learning from the mistakes of others. J Eval Clin Pract. 2014;20(4):505-7. doi:10.1111/jep.12165. https://psnet.ahrq.gov/issue/risk-management-learning-mistakes-others This commentary introduces a structured process for …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46944/psn-pdf
    March 21, 2018 - Critical Deficiencies at the Washington DC VA Medical Center. March 21, 2018 Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. Report No. 17-02644-130. https://psnet.ahrq.gov/issue/critical-deficiencies-washington-dc-va-medical-center Systemic weaknesses in the Veterans A…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39408/psn-pdf
    March 31, 2010 - Patient safety: numerical skills and drug calculation abilities of nursing students and Registered Nurses. March 31, 2010 McMullan M, Jones R, Lea S. Patient safety: numerical skills and drug calculation abilities of nursing students and Registered Nurses. J Adv Nurs. 2010;66(4). doi:10.1111/j.1365-2648.2010.05258.…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60997/psn-pdf
    October 07, 2020 - ‘You’re going to release him when he was hurting himself?’ October 7, 2020 Dahlberg B. Kaiser Health News. September 29, 2020. https://psnet.ahrq.gov/issue/youre-going-release-him-when-he-was-hurting-himself This story discusses failures related emergency psychiatric assessment, including premature discharge, imp…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847731/psn-pdf
    April 19, 2023 - Lessons from health care leaders: rethinking and reinvesting in patient safety. April 19, 2023 doi:10.1056/CAT.23.0090. https://psnet.ahrq.gov/issue/lessons-health-care-leaders-rethinking-and-reinvesting-patient-safety Progress in patient safety has been disappointingly slow. This commentary shares thoughts from a…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38925/psn-pdf
    September 16, 2009 - A literature review of the individual and systems factors that contribute to medication errors in nursing practice. September 16, 2009 Brady A-M, Malone A-M, Fleming S. A literature review of the individual and systems factors that contribute to medication errors in nursing practice. J Nurs Manag. 2009;17(6):679-97…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41453/psn-pdf
    November 26, 2014 - Judging whether a patient is actually improving: more pitfalls from the science of human perception. November 26, 2014 Redelmeier DA, Dickinson VM. Judging whether a patient is actually improving: more pitfalls from the science of human perception. J Gen Intern Med. 2012;27(9):1195-9. doi:10.1007/s11606-012-2097-2.…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863003/psn-pdf
    February 21, 2024 - Positive Patient Identification. February 21, 2024 Healthcare Safety Investigation Branch (HSIB), Dorset, UK:  Health Services Safety Investigations Body; February 2024. https://psnet.ahrq.gov/issue/positive-patient-identification Patient misidentification can result in medication administration errors, …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43829/psn-pdf
    January 14, 2015 - The high cost of low morale in the clinical laboratory: how workplace environment impacts patient safety. January 14, 2015 Barker T; Noguez J. https://psnet.ahrq.gov/issue/high-cost-low-morale-clinical-laboratory-how-workplace-environment-impacts- patient-safety Reporting on the importance of a supportive workpla…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838638/psn-pdf
    September 01, 2012 - Directed peer review in surgical pathology. September 1, 2012 Smith ML, Raab SS. Directed peer review in surgical pathology. Adv Anat Pathol. 2012;19(5):331-337. doi:10.1097/pap.0b013e31826661b7. https://psnet.ahrq.gov/issue/directed-peer-review-surgical-pathology Diagnostic error in pathology can result in delaye…