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8381. Table of Contents: Volume 4. Technology and Medication Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/TableofContents_Vol4.pdf
      January 01, 2025 - Table of Contents: Volume 4. Technology and Medication Safety Contents Volume 4. Technology and Medication Safety Prologue: Technology and Medication Safety Mary L. Grady Health Information Technology “Safeware”: Safety-Critical Computing and Health Care Information Technology Robert L. Wears, Nancy G. Lev…

8382. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. | PSNet
      psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
      May 01, 2005 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. Citation Text: Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…

8383. Assessing Readiness, Achievement & Impact of Stage 3 Care Coordination Criteria - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs022674-adler-milstein-final-report-2014.pdf
      January 01, 2014 - Threading of hospital communications and ability to have EHR systems recognize and flag incoming communication

8384. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44232/psn-pdf
      January 29, 2019 - Optimizing medication safety in the home. January 29, 2019 LeBlanc RG, Choi J. Optimizing medication safety in the home. Home Healthc Now. 2015;33(6):313-319. doi:10.1097/NHH.0000000000000246. https://psnet.ahrq.gov/issue/optimizing-medication-safety-home Patients who receive home care services are vulnerable to a…

8385. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60527/psn-pdf
      May 27, 2020 - The flaw of medicine: addressing racial and gender disparities in critical care. May 27, 2020 Hilton EJ, Goff KL, Sreedharan R, et al. The flaw of medicine: addressing racial and gender disparities in critical care. Anesthesiol Clin. 2020;38(2):357-368. doi:10.1016/j.anclin.2020.01.011. https://psnet.ahrq.gov/issu…

8386. AHRQ's Safety Program for Nursing Homes: On-Time Prevention | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/qualifications.html
      December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Prevention Facilitator Training—Recommended Facilitator Trainee Qualifications Know about adult learning principles and have experience training adults. Can adjust the technical complexity of the content to the audience's level of understanding. Have exce…

8387. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42157/psn-pdf
      April 22, 2013 - High performance teamwork training and systems redesign in outpatient oncology. April 22, 2013 Bunnell CA, Gross AH, Weingart SN, et al. High performance teamwork training and systems redesign in outpatient oncology. BMJ Qual Saf. 2013;22(5):405-13. doi:10.1136/bmjqs-2012-000948. https://psnet.ahrq.gov/issue/high-…

8388. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33889/psn-pdf
      January 04, 2017 - John M. Eisenberg Patient Safety Awards. System innovation: Concord Hospital. January 4, 2017 Uhlig PN, Brown J, Nason AK, et al. John M. Eisenberg Patient Safety Awards. System innovation: Concord Hospital. Jt Comm J Qual Improv. 2002;28(12):666-672. https://psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-aw…

8389. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45926/psn-pdf
      May 17, 2017 - Toolkit To Improve Safety in Ambulatory Surgery Centers. May 17, 2017 Rockville, MD: Agency for Healthcare Research and Quality; December 2014. https://psnet.ahrq.gov/issue/toolkit-improve-safety-ambulatory-surgery-centers Ambulatory surgery centers provide care to growing numbers of patients. This toolkit draws fr…

8390. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39491/psn-pdf
      March 22, 2011 - The published literature on handoffs in hospitals: deficiencies identified in an extensive review. March 22, 2011 Cohen MD, Hilligoss B. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Qual Saf Health Care. 2010;19(6):493-7. doi:10.1136/qshc.2009.033480. https://p…

8391. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851927/psn-pdf
      August 02, 2023 - Perioperative Handoffs. August 2, 2023 Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434. https://psnet.ahrq.gov/issue/perioperative-handoffs Handoffs occur several times during a surgical procedure, increasing the risk of communication mistakes and misunderstandings. This special…

8392. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74249/psn-pdf
      January 12, 2022 - Medication safety issues with newly authorized PAXLOVID. January 12, 2022 Institute for Safe Medication Practices. Medication Safety Alerts. January 3, 2022. https://psnet.ahrq.gov/issue/medication-safety-issues-newly-authorized-paxlovid Emerging care practices can produce unsafe situations due to the newness…

8393. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43714/psn-pdf
      December 17, 2014 - ER doctor discusses role in Ebola patient's initial misdiagnosis. December 17, 2014 Dunklin R, Thompson S. Dallas Morning News. December 6, 2014. https://psnet.ahrq.gov/issue/er-doctor-discusses-role-ebola-patients-initial-misdiagnosis This news article reports on the widely publicized delayed diagnosis of Ebola a…

8394. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47477/psn-pdf
      November 14, 2018 - Losing Laura. November 14, 2018 DeMarco P. Globe Magazine. November 3, 2018. https://psnet.ahrq.gov/issue/losing-laura This magazine article reports on the preventable death of a patient during an acute asthma attack. Written by the patient's husband, the article outlines the failures that led to her death despite…

8395. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74043/psn-pdf
      September 18, 2023 - DAISY Award for Extraordinary Nurses in Patient Safety. September 18, 2023 The Daisy Foundation and Institute for Healthcare Improvement. https://psnet.ahrq.gov/issue/daisy-award-extraordinary-nurses-patient-safety Nurses have a fundamental role in safe care delivery by fostering a healthy work environment. This aw…

8396. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50874/psn-pdf
      February 05, 2020 - Checking In on the Checklist. February 5, 2020 Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020. https://psnet.ahrq.gov/issue/checking-checklist Checklists are integrated into error reduction strategies and healthcare team communication efforts worldwide but implementation and impact of the tool varies …

8397. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851926/psn-pdf
      August 02, 2023 - Improving Patient Safety Culture – A Practical Guide. August 2, 2023 London, UK: NHS England; July 2023. https://psnet.ahrq.gov/issue/improving-patient-safety-culture-practical-guide A strong patient safety culture needs nurturing to serve as a foundation for launching and sustaining improvements. This toolkit pro…

8398. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39182/psn-pdf
      May 22, 2019 - ACOG Committee Opinion No. 447: patient safety in obstetrics and gynecology. May 22, 2019 Improvement AC of O and GCC on PS and Q. ACOG Committee Opinion No. 447: Patient safety in obstetrics and gynecology. Obstet Gynecol. 2009;114(6):1424-7. doi:10.1097/AOG.0b013e3181c6f90e. https://psnet.ahrq.gov/issue/acog-com…

8399. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38325/psn-pdf
      September 29, 2017 - Health care professionals' views of implementing a policy of open disclosure of errors. September 29, 2017 Sorensen R, Iedema R, Piper D, et al. Health care professionals' views of implementing a policy of open disclosure of errors. J Health Serv Res Policy. 2008;13(4):227-32. doi:10.1258/jhsrp.2008.008062. https:…

8400. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37154/psn-pdf
      September 02, 2015 - Health Literacy and Patient Safety: Help Patients Understand. Manual for Clinicians. 2nd ed. September 2, 2015 Weiss BD. Chicago, IL: American Medical Association Foundation; 2007. https://psnet.ahrq.gov/issue/health-literacy-and-patient-safety-help-patients-understand-manual-clinicians- 2nd-ed This book provides…