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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35588/psn-pdf
    February 03, 2011 - Creating a safer health care system: finding the constraint. February 3, 2011 Pauker SG, Zane EM, Salem D. Creating a safer health care system: finding the constraint. JAMA. 2005;294(22):2906-8. https://psnet.ahrq.gov/issue/creating-safer-health-care-system-finding-constraint This editorial builds on the discussi…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43721/psn-pdf
    December 03, 2014 - Predicting potential postdischarge adverse drug events and 30-day unplanned hospital readmissions from medication regimen complexity. December 3, 2014 Schoonover H, Corbett CF, Weeks DL, et al. Predicting potential postdischarge adverse drug events and 30-day unplanned hospital readmissions from medication regimen…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37011/psn-pdf
    September 24, 2010 - What do medical records tell us about potentially harmful co-prescribing? September 24, 2010 Lafata JE, Simpkins J, Kaatz S, et al. What do medical records tell us about potentially harmful co- prescribing? Jt Comm J Qual Patient Saf. 2007;33(7):395-400. https://psnet.ahrq.gov/issue/what-do-medical-records-tell-us…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44568/psn-pdf
    October 21, 2015 - Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. October 21, 2015 Bagian JP, Lee C, Gosbee J, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. J…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45943/psn-pdf
    March 15, 2017 - Identifying and reducing complications after emergency room discharge. March 15, 2017 Hofmann PB, Bagian JP. Patient Saf Qual Healthc. February 20, 2017. https://psnet.ahrq.gov/issue/identifying-and-reducing-complications-after-emergency-room-discharge Emergency departments are complex environments that harbor fac…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837432/psn-pdf
    June 15, 2022 - Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups. June 15, 2022 ISMP Medication Safety Alert! Acute care edition. June 2, 2022;27(11):1-4. https://psnet.ahrq.gov/issue/adopt-strategies-manage-look-alike-andor-sound-alike-medication-name-mix- ups Minimizing look-alike/sound-alike me…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45304/psn-pdf
    June 28, 2017 - Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices. June 28, 2017 Armstrong GE, Dietrich M, Norman L, et al. Nurses? Perceived Skills and Attitudes About Updated Safety Concepts. J Nurs Care Qual. 2016;32(3):226-233. doi:10.1097/ncq.000000…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861778/psn-pdf
    January 31, 2024 - Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee. January 31, 2024 Washington, DC: The Veterans Affairs Inspector General; January 10, 2024. Report No. 23-00777-52. https://psnet.ahrq.gov/issue/care-deficiencies-and-l…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47729/psn-pdf
    April 10, 2019 - Reclaiming the systems approach to paediatric safety. April 10, 2019 Cheung R, Roland D, Lachman P. Reclaiming the systems approach to paediatric safety. Arch Dis Child. 2019;104(12):1130-1133. doi:10.1136/archdischild-2018-316401. https://psnet.ahrq.gov/issue/reclaiming-systems-approach-paediatric-safety Children…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866856/psn-pdf
    October 02, 2024 - ASPEN survey of parenteral nutrition access issues: how the system fails the patients. October 2, 2024 Mirtallo JM, Allen P, Book WM, et al. ASPEN survey of parenteral nutrition access issues: how the system fails the patient. Nutr Clin Pract. 2024;39(5):1164-1181. doi:10.1002/ncp.11187. https://psnet.ahrq.gov/iss…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46996/psn-pdf
    May 23, 2018 - How to incorporate quality improvement and patient safety projects in your training. May 23, 2018 Siddique SM, Ketwaroo G, Newberry C, et al. How to Incorporate Quality Improvement and Patient Safety Projects in Your Training. Gastroenterology. 2018;154(6):1564-1568. doi:10.1053/j.gastro.2018.03.044. https://psnet…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837805/psn-pdf
    August 10, 2022 - Adverse events in infants less than 6 months of age after ambulatory surgery and diagnostic imaging requiring anesthesia. August 10, 2022 Uffman JC, Kim SS, Quan LN, et al. Adverse events in infants less than 6 months of age after ambulatory surgery and diagnostic imaging requiring anesthesia. Pediatr Qual Saf. 20…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39638/psn-pdf
    July 02, 2014 - Teaching quality improvement and patient safety to trainees: a systematic review. July 2, 2014 Wong BM, Etchells E, Kuper A, et al. Teaching quality improvement and patient safety to trainees: a systematic review. Acad Med. 2010;85(9):1425-39. doi:10.1097/ACM.0b013e3181e2d0c6. https://psnet.ahrq.gov/issue/teaching…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40220/psn-pdf
    March 21, 2012 - Incidence and preventability of adverse events requiring intensive care admission: a systematic review. March 21, 2012 Vlayen A, Verelst S, Bekkering GE, et al. Incidence and preventability of adverse events requiring intensive care admission: a systematic review. J Eval Clin Pract. 2012;18(2):485-97. doi:10.1111/j…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44323/psn-pdf
    December 04, 2016 - Client, caregiver, and provider perspectives of safety in palliative home care: a mixed method design. December 4, 2016 Lang A, Toon L, Cohen SR, et al. Client, caregiver, and provider perspectives of safety in palliative home care: a mixed method design. Safety Health. 2015;1(1):3. doi:10.1186/2056-5917-1-3. http…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838185/psn-pdf
    September 28, 2022 - How to mitigate the effects of cognitive biases during patient safety incident investigations. September 28, 2022 Rogers JE, Hilgers TR, Keebler JR, et al. How to mitigate the effects of cognitive biases during patient safety incident investigations. Jt Comm J Qual Patient Saf. 2022;48(11):612-616. doi:10.1016/j.j…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866075/psn-pdf
    June 05, 2024 - Oncology patients' willingness to report their medication safety concerns from home: a qualitative study. June 5, 2024 Bunni D, Walters G, Hwang M, et al. Oncology patients’ willingness to report their medication safety concerns from home: a qualitative study. Support Care Cancer. 2024;32(6):352. doi:10.1007/s00520…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846149/psn-pdf
    March 15, 2023 - Medication errors in community pharmacies: evaluation of a standardized safety program. March 15, 2023 Ledlie S, Gomes T, Dolovich L, et al. Medication errors in community pharmacies: evaluation of a standardized safety program. Explor Res Clin Soc Pharm. 2023;9:100218. doi:10.1016/j.rcsop.2022.100218. https://ps…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45996/psn-pdf
    May 10, 2017 - Evaluation of medication-related clinical decision support alert overrides in the intensive care unit. May 10, 2017 Wong A, Amato MG, Seger DL, et al. Evaluation of medication-related clinical decision support alert overrides in the intensive care unit. J Crit Care. 2017;39:156-161. doi:10.1016/j.jcrc.2017.02.027. …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73353/psn-pdf
    June 02, 2021 - Enhancing high alert medication knowledge among pharmacy, nursing, and medical staff. June 2, 2021 Sullivan KM, Le PL, Ditoro MJ, et al. Enhancing high alert medication knowledge among pharmacy, nursing, and medical staff. J Patient Saf. 2021;17(4):311-315. doi:10.1097/pts.0b013e3182878113. https://psnet.ahrq.gov/…
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