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psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
November 03, 2015 - Although the decision to come to work while ill appears at first glance to be an individual choice, it … Both logistic resources and social supports are required to make the choice to prioritize patient safety
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psnet.ahrq.gov/web-mm/medication-overdose
September 01, 2011 - involved incorrect dosing in 34% of these cases.( 5 )
Errors in drug ordering include errors in drug choice … Related to drug ordering is prescription transcription, as accurately conveying the drug choice or dose
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psnet.ahrq.gov/web-mm/anesthesia-weighty-issue
September 01, 2006 - lateral position required for the procedure, a laryngeal mask airway (LMA) may have been a suboptimal choice … An LMA turns out to be a poor choice for a recruitment maneuver.
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psnet.ahrq.gov/node/49641/psn-pdf
November 01, 2011 - have been reported in HBsAg-positive patients treated with
chemotherapy for lymphoma.(15)
Timing and choice … An opinion should be sought from a
specialist with regard to choice of antiviral therapy and duration
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psnet.ahrq.gov/node/46790/psn-pdf
March 14, 2018 - When clinicians drop out and start over after adverse
events.
March 14, 2018
Rodriquez J, Scott SD. When Clinicians Drop Out and Start Over after Adverse Events. Jt Comm J Qual
Patient Saf. 2018;44(3):137-145. doi:10.1016/j.jcjq.2017.08.008.
https://psnet.ahrq.gov/issue/when-clinicians-drop-out-and-start-over-afte…
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psnet.ahrq.gov/node/46213/psn-pdf
June 28, 2017 - The second victim: a review.
June 28, 2017
Coughlan B, Powell D, Higgins MF. The Second Victim: a Review. Eur J Obstet Gynecol Reprod Biol.
2017;213:11-16. doi:10.1016/j.ejogrb.2017.04.002.
https://psnet.ahrq.gov/issue/second-victim-review
Maternity care is a high-risk environment. This review discusses second vic…
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - Whether to obtain imaging, and the choice of imaging procedures, to investigate acute abdominal pain … imaging modality to pursue.3
Background – Imaging (2)
Ultrasonography is the initial imaging test of choice … ACR guidelines are available to guide physician choice of appropriate imaging.
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psnet.ahrq.gov/web-mm/lung-nodule-refused-grow
March 01, 2004 - However, as long as this choice was the product of thoughtful deliberation that considered the risk of … carries a higher risk of pneumothorax requiring chest tube placement (~7%).( 14 ) At this point, the choice … Help the patient make the best choice between CT surveillance, non-surgical biopsy, and surgical diagnosis
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psnet.ahrq.gov/node/46623/psn-pdf
July 02, 2019 - Factors contributing to medication errors made when
using computerized order entry in pediatrics: a
systematic review.
July 2, 2019
Tolley CL, Forde NE, Coffey KL, et al. Factors contributing to medication errors made when using
computerized order entry in pediatrics: a systematic review. J Am Med Info Assoc. 2017…
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psnet.ahrq.gov/node/60763/psn-pdf
August 05, 2020 - Supporting the emotional well-being of health care
workers during the COVID-19 pandemic.
August 5, 2020
Wu AW, Buckle P, Haut ER, et al. Supporting the emotional well-being of health care workers during the
COVID-19 pandemic. J Patient Saf Risk Manag. 2020;25(3):93-96. doi:10.1177/2516043520931971.
https://psnet.a…
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psnet.ahrq.gov/node/72476/psn-pdf
November 18, 2020 - Maintaining perioperative safety in uncertain times:
COVID-19 pandemic response strategies.
November 18, 2020
Mazzola SM, Grous C. Maintaining perioperative safety in uncertain times: COVID-19 pandemic response
strategies. AORN J. 2020;112(4):397-405. doi:10.1002/aorn.13195.
https://psnet.ahrq.gov/issue/maintainin…
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psnet.ahrq.gov/node/47465/psn-pdf
October 17, 2018 - Mix-ups between epidural analgesia and IV antibiotics in
labor and delivery units continue to cause harm.
October 17, 2018
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.
https://psnet.ahrq.gov/issue/mix-ups-between-epidural-analgesia-and-iv-antibiotics-labor-and-delivery-
units-continue-…
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psnet.ahrq.gov/node/73303/psn-pdf
May 26, 2021 - Safety Culture in EMS
May 26, 2021
Cebollero C, Fitall E, Hall KK, et al. Safety Culture in EMS. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/safety-culture-ems
Defining a Just Culture
A Just Culture is one that supports transparent and honest error reporting with the goal of fostering an
environmen…
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psnet.ahrq.gov/node/33645/psn-pdf
February 01, 2007 - On making the right choice: the deliberation-
without-attention effect.
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psnet.ahrq.gov/node/60294/psn-pdf
May 06, 2020 - Medically-necessary, time-sensitive procedures: a
scoring system to ethically and efficiently manage
resource scarcity and provider risk during the COVID-19
pandemic.
May 6, 2020
Prachand VN, Milner R, Angelos P, et al. Medically-necessary, time-sensitive procedures: a scoring system
to ethically and efficiently …
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psnet.ahrq.gov/node/50613/psn-pdf
October 30, 2019 - well-being of
the mom and the infant as being an either/or proposition, when it's actually a false choice … That means we often arrive in these fork-in-the-road moments, where there's a dichotomous choice that … The fork-in-the-road choice is
between the right thing to do and the easy thing to do.
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psnet.ahrq.gov/node/44280/psn-pdf
July 15, 2015 - Innovation in practice: a multidisciplinary medication
safety initiative.
July 15, 2015
Eid KA. Innovation in practice: A multidisciplinary medication safety initiative. Nursing. 2015;45(7):14-6.
doi:10.1097/01.NURSE.0000466458.62870.99.
https://psnet.ahrq.gov/issue/innovation-practice-multidisciplinary-medication…
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psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
July 08, 2022 - capacity: 2
Understanding: The ability to state the meaning of the relevant information
Expressing a choice … to define the decision that the patient has to make and identify the consequences for each possible choice … It is important to remember that patients do not need to make the “correct choice”; however, they do
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psnet.ahrq.gov/node/49643/psn-pdf
December 01, 2011 - Studies show that when informed patients are given the choice
between more aggressive care and a less … Decision aids and breast cancer: do they influence choice for
surgery and knowledge of treatment options
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psnet.ahrq.gov/node/73068/psn-pdf
March 24, 2021 - The perception of patient safety in an alternate site of
care for elective surgery during the first wave of the novel
coronavirus pandemic in the United Kingdom: a survey of
158 patients.
March 24, 2021
Lee G, Clough OT, Walker JA, et al. The perception of patient safety in an alternate site of care for elective
…