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  1. Learn From Defects - Implementation Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/learn.html
    April 01, 2017 - Learn From Defects - Implementation Guide AHRQ Safety Program for Ambulatory Surgery Purpose: To identify the types of systems that contributed to the defect (an event or situation that you do not want to happen again) and to plan the followup steps needed to improve safety. Who should use this tool? Seni…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45989/psn-pdf
    June 07, 2017 - Radiologic safety events within a pediatric emergency medicine network. June 7, 2017 Blumberg SM, Mahajan P, O?Connell KJ, et al. Radiologic Safety Events Within a Pediatric Emergency Medicine Network. Pediatr Emerg Care. 2017;33(2):92-96. doi:10.1097/PEC.0000000000000684. https://psnet.ahrq.gov/issue/radiologic-s…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46123/psn-pdf
    January 01, 2020 - Improving patient safety in handover from intensive care unit to general ward: a systematic review. June 21, 2017 Wibrandt I, Lippert A. Improving Patient Safety in Handover From Intensive Care Unit to General Ward: A Systematic Review. J Patient Saf. 2020;16(3):199-210. doi:10.1097/pts.0000000000000266. https://p…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37178/psn-pdf
    October 06, 2011 - Randomized trial to improve prescribing safety in ambulatory elderly patients. October 6, 2011 Raebel MA, Charles J, Dugan J, et al. Randomized trial to improve prescribing safety in ambulatory elderly patients. J Am Geriatr Soc. 2007;55(7):977-85. https://psnet.ahrq.gov/issue/randomized-trial-improve-prescribing-…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45420/psn-pdf
    December 04, 2016 - Patients' perception of types of errors in palliative care—results from a qualitative interview study. December 4, 2016 Kiesewetter I, Schulz CM, Bausewein C, et al. Patients' perception of types of errors in palliative care - results from a qualitative interview study. BMC Palliat Care. 2016;15(1):75. doi:10.1186/…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50658/psn-pdf
    November 13, 2019 - Thresholds, rules and defensive strategies: how physicians learn from their prior diagnosis-related experiences. November 13, 2019 Donner-Banzhoff N, Müller B, Beyer M, et al. Thresholds, rules and defensive strategies: how physicians learn from their prior diagnosis-related experiences. Diagnosis (Berl). 2019;7(2…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47628/psn-pdf
    March 13, 2019 - Prescribing in 2019: what are the safety concerns? March 13, 2019 Coleman JJ. Prescribing in 2019: what are the safety concerns? Expert Opin Drug Saf. 2019;18(2):69-74. doi:10.1080/14740338.2019.1571038. https://psnet.ahrq.gov/issue/prescribing-2019-what-are-safety-concerns Medication errors present challenges to …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47264/psn-pdf
    October 03, 2018 - Potentially inappropriate opioid prescribing, overdose, and mortality in Massachusetts, 2011–2015. October 3, 2018 Rose AJ, Bernson D, Chui KKH, et al. Potentially Inappropriate Opioid Prescribing, Overdose, and Mortality in Massachusetts, 2011-2015. J Gen Intern Med. 2018;33(9):1512-1519. doi:10.1007/s11606-018-45…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47862/psn-pdf
    April 08, 2019 - Assessing the use of Google Translate for Spanish and Chinese translations of emergency department discharge instructions. April 8, 2019 Khoong EC, Steinbrook E, Brown C, et al. Assessing the Use of Google Translate for Spanish and Chinese Translations of Emergency Department Discharge Instructions. JAMA Intern Me…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60947/psn-pdf
    September 23, 2020 - FDA Advise-ERR: reported medication errors with Veklury (remdesivir) emergency use authorization. September 23, 2020 ISMP Medication Safety Alert! Acute care edition. September 10, 2020;25(18) https://psnet.ahrq.gov/issue/fda-advise-err-reported-medication-errors-veklury-remdesivir-emergency-use- authorizatio…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47278/psn-pdf
    August 15, 2018 - Drawing boundaries: the difficulty in defining clinical reasoning. August 15, 2018 Young M, Thomas A, Lubarsky S, et al. Drawing Boundaries: The Difficulty in Defining Clinical Reasoning. Acad Med. 2018;93(7):990-995. doi:10.1097/ACM.0000000000002142. https://psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defi…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47816/psn-pdf
    June 26, 2019 - Clinical reasoning assessment methods: a scoping review and practical guidance. June 26, 2019 Daniel M, Rencic J, Durning SJ, et al. Clinical Reasoning Assessment Methods: A Scoping Review and Practical Guidance. Acad Med. 2019;94(6):902-912. doi:10.1097/ACM.0000000000002618. https://psnet.ahrq.gov/issue/clinical-…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836718/psn-pdf
    March 09, 2022 - Systems engineering analysis of diagnostic referral closed-loop processes. March 9, 2022 Nehls N, Yap TS, Salant T, et al. Systems engineering analysis of diagnostic referral closed-loop processes. BMJ Open Qual. 2021;10(4):e001603. doi:10.1136/bmjoq-2021-001603. https://psnet.ahrq.gov/issue/systems-engineering-an…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34787/psn-pdf
    March 28, 2005 - Medication misadventures resulting in emergency department visits at an HMO medical center. March 28, 2005 Schneitman-McIntire O, Farnen TA, Gordon N, et al. Am J Health Syst Pharm. 1996;53(12):1416-1422. https://psnet.ahrq.gov/issue/medication-misadventures-resulting-emergency-department-visits-hmo- medical-cente…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72830/psn-pdf
    March 10, 2021 - Families are struggling to use medicines at home — we must truly involve them in their own safety. March 10, 2021 Morris S, O’Hara J. Pharmacuetical Journal. February 26, 2021. https://psnet.ahrq.gov/issue/families-are-struggling-use-medicines-home-we-must-truly-involve-them-their- own-safety It is a ch…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47818/psn-pdf
    April 03, 2019 - Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors. April 3, 2019 Misasi P, Keebler JR. Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors. Ther Adv Drug Saf. 2019;10:204209861882…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47790/psn-pdf
    April 08, 2019 - The "hemolyzed" physical examination—situational challenges to accurate bedside diagnosis. April 8, 2019 Sargsyan Z. The "Hemolyzed" Physical Examination-Situational Challenges to Accurate Bedside Diagnosis. JAMA Intern Med. 2019;179(4):465-466. doi:10.1001/jamainternmed.2018.8753. https://psnet.ahrq.gov/issue/hem…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39621/psn-pdf
    June 23, 2010 - Defining near misses: towards a sharpened definition based on empirical data about error handling processes. June 23, 2010 Kessels-Habraken M, Van der Schaaf T, De Jonge J, et al. Defining near misses: towards a sharpened definition based on empirical data about error handling processes. Soc Sci Med. 2010;70(9):130…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47865/psn-pdf
    April 17, 2019 - The effect of a residential care pharmacist on medication administration practices in aged care: a controlled trial. April 17, 2019 McDerby N, Kosari S, Bail K, et al. The effect of a residential care pharmacist on medication administration practices in aged care: A controlled trial. J Clin Pharm Ther. 2019;44(4):5…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46642/psn-pdf
    December 13, 2017 - Intravenous fluid prescribing errors in children: mixed methods analysis of critical incidents. December 13, 2017 Conn RL, McVea S, Carrington A, et al. Intravenous fluid prescribing errors in children: Mixed methods analysis of critical incidents. PLoS One. 2017;12(10):e0186210. doi:10.1371/journal.pone.0186210. …
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