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3821. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60153/psn-pdf
      March 25, 2020 - A protocol for the safe use of hazardous drugs in the OR. March 25, 2020 Hemingway MW, Meleis L, Oliver J, et al. A protocol for the safe use of hazardous drugs in the OR. AORN J. 2020;111(3). doi:10.1002/aorn.12960. https://psnet.ahrq.gov/issue/protocol-safe-use-hazardous-drugs-or Perioperative personnel often ca…

3822. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60192/psn-pdf
      April 01, 2020 - Effective Reporting Could Improve Safe Use of Electronic Health Records. April 1, 2020 Philadelphia, PA: Pew Charitable Trusts; March 2020. https://psnet.ahrq.gov/issue/effective-reporting-could-improve-safe-use-electronic-health-records Electronic health records both enhance and challenge the safety of care proce…

3823. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43961/psn-pdf
      August 02, 2015 - Reducing inappropriate polypharmacy: the process of deprescribing. August 2, 2015 Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-34. doi:10.1001/jamainternmed.2015.0324. https://psnet.ahrq.gov/issue/reducing-inappropriate-pol…

3824. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46414/psn-pdf
      January 10, 2018 - Leveraging the electronic health record to improve quality and safety in rheumatology. January 10, 2018 Schmajuk G, Yazdany J. Leveraging the electronic health record to improve quality and safety in rheumatology. Rheumatol Int. 2017;37(10):1603-1610. doi:10.1007/s00296-017-3804-4. https://psnet.ahrq.gov/issue/lev…

3825. 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 …

3826. 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…

3827. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45303/psn-pdf
      June 15, 2017 - The global burden of diagnostic errors in primary care. June 15, 2017 Singh H, Schiff G, Graber ML, et al. The global burden of diagnostic errors in primary care. BMJ Qual Saf. 2017;26(6):484-494. doi:10.1136/bmjqs-2016-005401. https://psnet.ahrq.gov/issue/global-burden-diagnostic-errors-primary-care The need to i…

3828. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47387/psn-pdf
      September 12, 2018 - Guideline implementation: team communication. September 12, 2018 Link T. Guideline Implementation: Team Communication: 1.8 www.aornjournal.org/content/cme. AORN J. 2018;108(2):165-177. doi:10.1002/aorn.12300. https://psnet.ahrq.gov/issue/guideline-implementation-team-communication Although team development has rec…

3829. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44475/psn-pdf
      October 03, 2017 - Scoring no goal—further adventures in transparency. October 3, 2017 Rosenbaum L. Scoring No Goal--Further Adventures in Transparency. N Engl J Med. 2015;373(15):1385- 8. doi:10.1056/NEJMp1510094. https://psnet.ahrq.gov/issue/scoring-no-goal-further-adventures-transparency This commentary explores challenges to mon…

3830. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43458/psn-pdf
      August 27, 2014 - Validation of a teamwork perceptions measure to increase patient safety. August 27, 2014 Keebler JR, Dietz AS, Lazzara EH, et al. Validation of a teamwork perceptions measure to increase patient safety. BMJ Qual Saf. 2014;23(9):718-26. doi:10.1136/bmjqs-2013-001942. https://psnet.ahrq.gov/issue/validation-teamwork…

3831. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47485/psn-pdf
      January 09, 2019 - System-related and cognitive errors in laboratory medicine. January 9, 2019 Plebani M. System-related and cognitive errors in laboratory medicine. Diagnosis (Berl). 2018;5(4):191- 196. doi:10.1515/dx-2018-0085. https://psnet.ahrq.gov/issue/system-related-and-cognitive-errors-laboratory-medicine Problems managing …

3832. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46810/psn-pdf
      April 18, 2018 - Unintended doses in radiotherapy—over, under and outside? April 18, 2018 Eaton DJ, Byrne JP, Cosgrove VP, et al. Unintended doses in radiotherapy-over, under and outside? Br J Radiol. 2018;91(1084):20170863. doi:10.1259/bjr.20170863. https://psnet.ahrq.gov/issue/unintended-doses-radiotherapy-over-under-and-outside…

3833. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46630/psn-pdf
      November 15, 2017 - Patient Safety in the Office-Based Practice Setting. November 15, 2017 Philadelphia, PA: American College of Physicians; 2017. https://psnet.ahrq.gov/issue/patient-safety-office-based-practice-setting Patient safety in the ambulatory setting is gaining traction as a focus for research, intervention, and policy. Th…

3834. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42415/psn-pdf
      July 24, 2013 - Strategies for improving communication in the emergency department: mediums and messages in a noisy environment. July 24, 2013 Welch SJ, Cheung DS, Apker J, et al. Strategies for improving communication in the emergency department: mediums and messages in a noisy environment. Jt Comm J Qual Patient Saf. 2013;39(6)…

3835. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73255/psn-pdf
      May 12, 2021 - Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. May 12, 2021 National Academies of Sciences, Engineering, and Medicine 2021. Washington, DC: The National Academies Press. https://psnet.ahrq.gov/issue/implementing-high-quality-primary-care-rebuilding-foundation-health-care Primary…

3836. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44281/psn-pdf
      July 22, 2015 - Surgeon Scorecard. July 22, 2015 Wei S; Allen M; Pierce O. https://psnet.ahrq.gov/issue/surgeon-scorecard Transparency has been advocated as a key element of safe, patient-centered care, but data on individual performance has not been made widely available. This database compiles the death and complication rates …

3837. 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…

3838. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46301/psn-pdf
      October 11, 2017 - Care transitions know-how not just for clinicians. October 11, 2017 Ready T. HealthLeaders Media. September 26, 2017. https://psnet.ahrq.gov/issue/care-transitions-know-how-not-just-clinicians Transitions are an error-prone process. This news article reports that organizational leadership should be engaged in enha…

3839. 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…

3840. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42633/psn-pdf
      October 02, 2013 - Health IT-Enabled Quality Measurement: Perspectives, Pathways, and Practical Guidance. October 2, 2013 Roper RA, Anderson KM, Marsh CA, Flemming AC. Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13-0059-EF.  https://psnet.ahrq.gov/issue/health-it-enabled-quali…