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3501. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46192/psn-pdf
      June 07, 2017 - Investigating the causes of adverse events. June 7, 2017 Sanchez JA, Lobdell KW, Moffatt-Bruce SD, et al. Investigating the Causes of Adverse Events. Ann Thorac Surg. 2017;103(6):1693-1699. doi:10.1016/j.athoracsur.2017.04.001. https://psnet.ahrq.gov/issue/investigating-causes-adverse-events Incident analysis enab…

3502. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41738/psn-pdf
      June 10, 2018 - Inappropriate use of pharmacy bulk packages of IV contrast media increases risk of infections. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. September 20, 2012;17:1,3-4. https://psnet.ahrq.gov/issue/inappropriate-use-pharmacy-bulk-packages-iv-contrast-media-increases-risk- infections This articl…

3503. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44090/psn-pdf
      November 21, 2016 - Insensible losses: when the medical community forgets the family. November 21, 2016 Elias P. Insensible losses: when the medical community forgets the family. Health Aff (Millwood). 2015;34(4):707-710. doi:10.1377/hlthaff.2014.0536. https://psnet.ahrq.gov/issue/insensible-losses-when-medical-community-forgets-fami…

3504. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47003/psn-pdf
      July 18, 2018 - Impact of an antiretroviral stewardship strategy on medication error rates. July 18, 2018 Shea KM, Hobbs AL, Shumake JD, et al. Impact of an antiretroviral stewardship strategy on medication error rates. Am J Health Syst Pharm. 2018;75(12):876-885. doi:10.2146/ajhp170420. https://psnet.ahrq.gov/issue/impact-antire…

3505. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43316/psn-pdf
      July 02, 2014 - Optimizing transitions of care to reduce rehospitalizations. July 2, 2014 Li J, Young R, Williams M. Optimizing transitions of care to reduce rehospitalizations. Cleve Clin J Med. 2014;81(5):312-20. doi:10.3949/ccjm.81a.13106. https://psnet.ahrq.gov/issue/optimizing-transitions-care-reduce-rehospitalizations Care…

3506. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43052/psn-pdf
      March 19, 2014 - Surgical ward round quality and impact on variable patient outcomes. March 19, 2014 Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg. 2014;259(2):222-6. doi:10.1097/SLA.0000000000000376. https://psnet.ahrq.gov/issue/surgical-ward-round-quality-and-impact…

3507. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36884/psn-pdf
      May 27, 2011 - Evaluation of outpatient computerized physician medication order entry systems: a systematic review. May 27, 2011 Eslami S, Abu-Hanna A, de Keizer NF. Evaluation of outpatient computerized physician medication order entry systems: a systematic review. J Am Med Inform Assoc. 2007;14(4):400-6. https://psnet.ahrq.gov…

3508. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39374/psn-pdf
      March 17, 2010 - Bridging the gap: leveraging business intelligence tools in support of patient safety and financial effectiveness. March 17, 2010 Ferranti JM, Langman MK, Tanaka D, et al. Bridging the gap: leveraging business intelligence tools in support of patient safety and financial effectiveness. J Am Med Inform Assoc. 2010;1…

3509. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38644/psn-pdf
      May 20, 2009 - A quality initiative to decrease pathology specimen- labeling errors using radiofrequency identification in a high-volume endoscopy center. May 20, 2009 Francis DL, Prabhakar S, Sanderson SO. A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume en…

3510. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44270/psn-pdf
      July 01, 2015 - Improving Patient Safety Culture Through Teamwork and Communication: TeamSTEPPS. July 1, 2015 Chicago, IL: Health Research & Educational Trust; June 2015. https://psnet.ahrq.gov/issue/improving-patient-safety-culture-through-teamwork-and-communication- teamstepps This guide draws from the experience of organizati…

3511. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44718/psn-pdf
      November 25, 2015 - Beyond the Quick Fix: Strategies for Improving Patient Safety. November 25, 2015 Baker GR. Toronto, ON: Institute of Health Policy, Management and Evaluation, University of Toronto; 2015. https://psnet.ahrq.gov/issue/beyond-quick-fix-strategies-improving-patient-safety The 2004 Canadian Adverse Events Study helpe…

3512. Psn-Pdf (pdf file)
      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…

3513. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43218/psn-pdf
      July 28, 2014 - Risk management—learning from the mistakes of others. July 28, 2014 Meydan C. Risk management--learning from the mistakes of others. J Eval Clin Pract. 2014;20(4):505-7. doi:10.1111/jep.12165. https://psnet.ahrq.gov/issue/risk-management-learning-mistakes-others This commentary introduces a structured process for …

3514. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43373/psn-pdf
      July 23, 2014 - From harm to hope and purposeful action: what could we do after Francis? July 23, 2014 Woodhead T, Lachman P, Mountford J, et al. From harm to hope and purposeful action: what could we do after Francis? BMJ Qual Saf. 2014;23(8):619-23. doi:10.1136/bmjqs-2013-002581. https://psnet.ahrq.gov/issue/harm-hope-and-purpo…

3515. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50568/psn-pdf
      October 23, 2019 - Automation of the I-PASS tool to improve transitions of care. October 23, 2019 Skaret MM, Weaver TD, Humes RJ, et al. Automation of the I-PASS Tool to Improve Transitions of Care. J Healthc Qual. 2019;41(5):274-280. doi:10.1097/JHQ.0000000000000174. https://psnet.ahrq.gov/issue/automation-i-pass-tool-improve-trans…

3516. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846167/psn-pdf
      March 15, 2023 - Diagnostic stewardship to prevent diagnostic error. March 15, 2023 Morgan DJ, Malani PN, Diekema DJ. Diagnostic stewardship to prevent diagnostic error. JAMA. 2023;329(15):1255-1256. doi:10.1001/jama.2023.1678. https://psnet.ahrq.gov/issue/diagnostic-stewardship-prevent-diagnostic-error The effective use of resour…

3517. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72734/psn-pdf
      February 10, 2021 - Meitheal Pharmaceuticals, Inc. issues voluntary nationwide recall of Cisatracurium Besylate Injection, USP 10mg per 5mL due to mislabeling. February 10, 2021 MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 27, 2021.   https://psnet.ahrq.gov/issue/meitheal-pharmaceuticals-inc…

3518. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36615/psn-pdf
      January 14, 2011 - The Patient Safety and Quality Improvement Act of 2005: provisions and potential opportunities. January 14, 2011 Liang BA, Riley W, Rutherford W, et al. The Patient Safety and Quality Improvement Act of 2005: Provisions and Potential Opportunities. American Journal of Medical Quality. 2007;22(1). doi:10.1177/10628…

3519. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45569/psn-pdf
      January 23, 2017 - Patient experience must move beyond bad apples. January 23, 2017 Hamedani A, Safdar B, Aaronson E, et al. Patient Experience Must Move Beyond Bad Apples. Ann Intern Med. 2016;165(12):869-870. doi:10.7326/M16-1725. https://psnet.ahrq.gov/issue/patient-experience-must-move-beyond-bad-apples Patient safety leaders ha…

3520. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42346/psn-pdf
      June 10, 2018 - Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. May 30, 2013;18:1-3. https://psnet.ahrq.gov/issue/fatal-pca-adverse-events-continue-happenbetter-patient-monitoring-essential- prevent-harm Describi…