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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45567/psn-pdf
    October 12, 2016 - Insulin Pens Devices. October 12, 2016 Am J Health Syst Pharm. 2016;73(19 suppl 5);s1-s47. https://psnet.ahrq.gov/issue/insulin-pens-devices As a high-alert medication, insulin has the potential to result in serious patient harm if administered incorrectly. Articles in this special issue discuss recommendations de…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41559/psn-pdf
    August 01, 2012 - Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO.' August 1, 2012 Iedema R, Ball C, Daly B, et al. Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO'. BMJ Qual Saf. 2012;21(8):627-33. doi:10.1136/bmjqs-2011-000766. https://psnet.ahr…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42961/psn-pdf
    February 19, 2014 - Healthcare-associated infections: a national patient safety problem and the coordinated response. February 19, 2014 Jeeva RR, Wright D. Healthcare-associated infections: a national patient safety problem and the coordinated response. Med Care. 2014;52(2 Suppl 1):S4-8. doi:10.1097/MLR.0b013e3182a54581. https://psne…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36106/psn-pdf
    May 27, 2011 - Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry. May 27, 2011 Rana R, Afessa B, Keegan MT, et al. Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry. Crit Care Med. 2006;34(7…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46422/psn-pdf
    November 29, 2017 - Framework for direct observation of performance and safety in healthcare. November 29, 2017 Catchpole K, Neyens DM, Abernathy J, et al. Framework for direct observation of performance and safety in healthcare. BMJ Qual Saf. 2017;26(12):1015-1021. doi:10.1136/bmjqs-2016-006407. https://psnet.ahrq.gov/issue/framewor…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39227/psn-pdf
    January 13, 2010 - Executive summary of the American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting: reinvigorating safety in office-based gynecologic surgery. January 13, 2010 Erickson TB, Kirkpatrick DH, DeFrancesco MS, et al. Executive summary of the American College of …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47289/psn-pdf
    October 24, 2018 - ASHP guidelines on managing drug product shortages. October 24, 2018 Fox ER, McLaughlin MM. ASHP guidelines on managing drug product shortages. Am J Health Syst Pharm. 2018;75(21):1742-1750. doi:10.2146/ajhp180441. https://psnet.ahrq.gov/issue/ashp-guidelines-managing-drug-product-shortages Drug shortages are a pe…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838031/psn-pdf
    September 13, 2022 - Addressing the Loss of Trust in Safety Culture. September 7, 2022 Philadelphia, PA: Building Trust and the ABIM Foundation; September 13, 2022.  https://psnet.ahrq.gov/issue/addressing-loss-trust-safety-culture Trust in patient safety processes encourages reporting of concerns, learning from error, and develop…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34570/psn-pdf
    March 07, 2005 - Measuring the Success of the Regional Medication Safety Program for Hospitals. March 7, 2005 Pelczarski K, Fricker M, Morris J. Philadelphia, PA: Health Care Improvement Foundation; 2005. https://psnet.ahrq.gov/issue/measuring-success-regional-medication-safety-program-hospitals The Regional Medication Safety Prog…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74114/psn-pdf
    November 24, 2021 - Addressing health care disparities by improving quality and safety. November 24, 2021 Sentinel Event Alert. Nov 10 2021;(64):1-7. https://psnet.ahrq.gov/issue/addressing-health-care-disparities-improving-quality-and-safety Health care disparities are emerging as a core patient safety issue. This alert introduces s…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40296/psn-pdf
    October 01, 2014 - Applying trigger tools to detect adverse events associated with outpatient surgery. October 1, 2014 Rosen AK, Mull HJ, Kaafarani HMA, et al. Applying trigger tools to detect adverse events associated with outpatient surgery. J Patient Saf. 2011;7(1):45-59. doi:10.1097/PTS.0b013e31820d164b. https://psnet.ahrq.gov/i…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37979/psn-pdf
    April 11, 2011 - Preliminary assessment of pediatric health care quality and patient safety in the United States using readily available administrative data. April 11, 2011 McDonald KM, Davies SM, Haberland CA, et al. Preliminary assessment of pediatric health care quality and patient safety in the United States using readily avai…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41973/psn-pdf
    January 30, 2013 - Implementation of a specialized pharmacy team to monitor high-risk medications during discharge. January 30, 2013 Martin ES, Overstreet RL, Jackson-Khalil LR, et al. Implementation of a specialized pharmacy team to monitor high-risk medications during discharge. Am J Health Syst Pharm. 2013;70(1):18-21. doi:10.214…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45800/psn-pdf
    January 18, 2017 - Inpatient Notes: mistakes in the hospital—communicating, apologizing, and beyond. January 18, 2017 Kachalia A. Web Exclusives. Annals for Hospitalists Inpatient Notes - Mistakes in the Hospital- Communicating, Apologizing, and Beyond. Ann Intern Med. 2016;165(12):HO2-HO3. doi:10.7326/M16- 2545. https://psnet.ahrq…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47667/psn-pdf
    February 27, 2019 - It is time to define antimicrobial never events. February 27, 2019 Liu J, Kaye KS, Mercuro NJ, et al. It is time to define antimicrobial never events. Infect Control Hosp Epidemiol. 2019;40(2):206-207. doi:10.1017/ice.2018.313. https://psnet.ahrq.gov/issue/it-time-define-antimicrobial-never-events Never events are…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847060/psn-pdf
    January 01, 2001 - The Emperor’s New Clothes: Or Whatever Happened To “Human Error”? January 1, 2001 Hollnagel E, Amalberti R. Chapter In: Dekker SWA, ed.  Proceedings of the 4th International Workshop on Human Error, Safety and Systems Development. Linköping Sweden: Linköping University; 2001. https://psnet.ahrq.gov/issu…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44408/psn-pdf
    April 12, 2017 - Enhancing Surgical Performance: A Primer in Non- technical Skills. April 12, 2017 Flin R, Youngson GG, Yule S. Boca Raton, FL: CRC Press; 2015. ISBN: 9781482246322. https://psnet.ahrq.gov/issue/enhancing-surgical-performance-primer-non-technical-skills Non-technical skill development is gaining attention as a way …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41306/psn-pdf
    May 04, 2012 - Identifying nontechnical skills associated with safety in the emergency department: a scoping review of the literature. May 4, 2012 Flowerdew L, Brown R, Vincent CA, et al. Identifying nontechnical skills associated with safety in the emergency department: a scoping review of the literature. Ann Emerg Med. 2012;59…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39914/psn-pdf
    October 13, 2010 - Clinical handover of patients arriving by ambulance to the emergency department: a literature review. October 13, 2010 Bost N, Crilly J, Wallis M, et al. Clinical handover of patients arriving by ambulance to the emergency department - a literature review. Int Emerg Nurs. 2010;18(4):210-20. doi:10.1016/j.ienj.2009.…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45007/psn-pdf
    March 30, 2016 - Medication errors involving healthcare students. March 30, 2016 Hess L, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. March 2016;13:18-23. https://psnet.ahrq.gov/issue/medication-errors-involving-healthcare-students Using reports of medication errors submitted to the Pennsylvania Patient Safety Authority that …
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