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psnet.ahrq.gov/node/74166/psn-pdf
March 14, 2022 - Preventing home medication administration errors.
March 14, 2022
Yin HS, Neuspiel DR, Paul IM, et al. Preventing home medication administration errors. Pediatrics.
2021;148(6):e2021054666. doi:10.1542/peds.2021-054666.
https://psnet.ahrq.gov/issue/preventing-home-medication-administration-errors
Children with comp…
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psnet.ahrq.gov/node/50909/psn-pdf
February 19, 2020 - Time to take hearing loss seriously.
February 19, 2020
Blustein J, Wallhagen MI, Weinstein BE, et al. Time to take hearing loss seriously. Jt Comm J Qual Patient
Saf. 2019;46(1):53-58. doi:10.1016/j.jcjq.2019.10.003.
https://psnet.ahrq.gov/issue/time-take-hearing-loss-seriously
The authors of this narrative review…
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psnet.ahrq.gov/node/74734/psn-pdf
January 19, 2024 - Disclosure of errors in surgical procedures.
January 19, 2024
Ryan M, Mekel M, Sinha MS. UptoDate. November 20, 2023.
https://psnet.ahrq.gov/issue/disclosure-errors-surgical-procedures
Error disclosure is fundamental to addressing harm and psychological distress after medical error. This
review highlights issues a…
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psnet.ahrq.gov/node/43658/psn-pdf
December 19, 2014 - Liability impact of the hospitalist model of care.
December 19, 2014
Schaffer A, Puopolo AL, Raman S, et al. Liability impact of the hospitalist model of care. J Hosp Med.
2014;9(12):750-5. doi:10.1002/jhm.2244.
https://psnet.ahrq.gov/issue/liability-impact-hospitalist-model-care
This review of closed malpractice …
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psnet.ahrq.gov/node/43654/psn-pdf
April 02, 2015 - Nursing bedside clinical handover—an integrated review
of issues and tools.
April 2, 2015
Anderson J, Malone L, Shanahan K, et al. Nursing bedside clinical handover - an integrated review of
issues and tools. J Clin Nurs. 2015;24(5-6):662-671. doi:10.1111/jocn.12706.
https://psnet.ahrq.gov/issue/nursing-bedside-cl…
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psnet.ahrq.gov/node/45885/psn-pdf
May 03, 2017 - E-collection: Safety and Error Prevention in Health.
May 3, 2017
https://psnet.ahrq.gov/issue/e-collection-safety-and-error-prevention-health
The increasing implementation of health information technology has introduced both benefits and
challenges to patient safety. Articles in this series explore the impacts of t…
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psnet.ahrq.gov/node/47904/psn-pdf
April 24, 2019 - Air pressure: human factors are the key to a safer flight
environment.
April 24, 2019
Erich J. EMS World. April 2019;48:26-31.
https://psnet.ahrq.gov/issue/air-pressure-human-factors-are-key-safer-flight-environment
Air transport service combines risks associated with both aviation and prehospital trauma care. Thi…
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psnet.ahrq.gov/node/48135/psn-pdf
August 28, 2019 - What causes prescribing errors in children? Scoping
review.
August 28, 2019
Conn RL, Kearney O, Tully MP, et al. What causes prescribing errors in children? Scoping review. BMJ
Open. 2019;9(8):e028680. doi:10.1136/bmjopen-2018-028680.
https://psnet.ahrq.gov/issue/what-causes-prescribing-errors-children-scoping-rev…
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psnet.ahrq.gov/node/43057/psn-pdf
January 01, 2015 - Health care huddles: managing complexity to achieve
high reliability.
December 12, 2014
Provost SM, Lanham H, Leykum LK, et al. Health care huddles: managing complexity to achieve high
reliability. Health Care Manage Rev. 2015;40(1):2-12. doi:10.1097/HMR.0000000000000009.
https://psnet.ahrq.gov/issue/health-care-h…
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psnet.ahrq.gov/node/44144/psn-pdf
May 27, 2015 - Maintaining safety in the dialysis facility.
May 27, 2015
Kliger AS. Maintaining safety in the dialysis facility. Clin J Am Soc Nephrol. 2015;10(4):688-95.
doi:10.2215/CJN.08960914.
https://psnet.ahrq.gov/issue/maintaining-safety-dialysis-facility
Failure to consider human factors and poor communication can contri…
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psnet.ahrq.gov/node/38055/psn-pdf
January 12, 2009 - Improving patient safety: patient-focused, high-reliability
team training.
January 12, 2009
McKeon LM, Cunningham PD, Oswaks JSD. Improving patient safety: patient-focused, high-reliability team
training. J Nurs Care Qual. 2009;24(1):76-82. doi:10.1097/NCQ.0b013e31818f5595.
https://psnet.ahrq.gov/issue/improving-p…
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psnet.ahrq.gov/node/72861/psn-pdf
March 17, 2021 - Keeping patients on track with preventative care during
pandemic.
March 17, 2021
Quick Safety. March 2021;58:1-2.
https://psnet.ahrq.gov/issue/keeping-patients-track-preventative-care-during-pandemic
The potential exposure to COVID-19 continues to negatively influence patient care seeking activity. This
article r…
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psnet.ahrq.gov/node/34737/psn-pdf
November 19, 2015 - First, Do No Harm Part 1: A Case Study of Systems
Failure.
November 19, 2015
Chicago: Partnership for Patient Safety, Harvard Risk Management Foundation; 2000.
https://psnet.ahrq.gov/issue/first-do-no-harm-part-1-case-study-systems-failure
This video, produced by the Partnership for Patient Safety and the Harvard …
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psnet.ahrq.gov/node/50781/psn-pdf
January 08, 2020 - Harnessing the power of medical malpractice data to
improve patient care.
January 8, 2020
Siegal D, Swift J, Forget J, et al. Harnessing the power of medical malpractice data to improve patient care.
J Healthc Risk Manag. 2020;39(3):28-36. doi:10.1002/jhrm.21393.
https://psnet.ahrq.gov/issue/harnessing-power-medic…
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psnet.ahrq.gov/node/837907/psn-pdf
August 24, 2022 - ISMP Guidelines for Safe Medication Use in Perioperative
and Procedural Settings.
August 24, 2022
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.
https://psnet.ahrq.gov/issue/ismp-guidelines-safe-medication-use-perioperative-and-procedural-settings
Medication errors associated with surgery and…
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psnet.ahrq.gov/node/48167/psn-pdf
August 28, 2019 - ASHP guidelines on perioperative pharmacy services.
August 28, 2019
Bickham P, Golembiewski J, Meyer T, et al. ASHP guidelines on perioperative pharmacy services. Am J
Health Syst Pharm. 2019;76(12):903-820. doi:10.1093/ajhp/zxz073.
https://psnet.ahrq.gov/issue/ashp-guidelines-perioperative-pharmacy-services
Pharm…
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psnet.ahrq.gov/node/43541/psn-pdf
August 28, 2017 - A step toward high reliability: implementation of a daily
safety brief in a children's hospital.
August 28, 2017
Saysana M, McCaskey M, Cox E, et al. A Step Toward High Reliability: Implementation of a Daily Safety
Brief in a Children's Hospital. J Patient Saf. 2017;13(3):149-152. doi:10.1097/PTS.0000000000000131.
…
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psnet.ahrq.gov/node/838929/psn-pdf
October 26, 2022 - Toolkit To Improve Antibiotic Use in Ambulatory Care.
October 26, 2022
Rockville, MD: Agency for Healthcare Research and Quality; October 2022.
https://psnet.ahrq.gov/issue/toolkit-improve-antibiotic-use-ambulatory-care
Inappropriate antibiotic prescribing is associated with increased risk potential. This toolkit a…
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psnet.ahrq.gov/node/42720/psn-pdf
November 13, 2013 - Workplace bullying in the OR: results of a descriptive
study.
November 13, 2013
Chipps E, Stelmaschuk S, Albert NM, et al. Workplace Bullying in the OR: Results of a Descriptive Study.
AORN J. 2013;98(5). doi:10.1016/j.aorn.2013.08.015.
https://psnet.ahrq.gov/issue/workplace-bullying-or-results-descriptive-study
…
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psnet.ahrq.gov/node/37556/psn-pdf
November 21, 2016 - Unexpected intraoperative patient death: the imperatives
of family- and surgeon-centered care.
November 21, 2016
Taylor D, Hassan MA, Luterman A, et al. Unexpected intraoperative patient death: the imperatives of
family- and surgeon-centered care. Arch Surg. 2008;143(1):87-92. doi:10.1001/archsurg.2007.27.
https:/…