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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44625/psn-pdf
    November 20, 2015 - State-of-the-art usage of simulation in anesthesia: skills and teamwork. November 20, 2015 Krage R, Erwteman M. State-of-the-art usage of simulation in anesthesia: skills and teamwork. Curr Opin Anaesthesiol. 2015;28(6):727-34. doi:10.1097/ACO.0000000000000257. https://psnet.ahrq.gov/issue/state-art-usage-simulati…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47038/psn-pdf
    July 18, 2018 - Delivering Quality Health Services: A Global Imperative for Universal Health Coverage. July 18, 2018 Geneva, Switzerland: World Health Organization; July 2018. ISBN: 9789241513906. https://psnet.ahrq.gov/issue/delivering-quality-health-services-global-imperative-universal-health-coverage The Crossing the Quality C…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44032/psn-pdf
    April 01, 2015 - ACOG Committee Opinion #621: patient safety and health information technology. April 1, 2015 Improvement C on PS and Q, Management C on P. Committee opinion no. 621: Patient safety and health information technology. Obstet Gynecol. 2015;125(1):282-3. doi:10.1097/01.AOG.0000459867.14114.7a. https://psnet.ahrq.gov/i…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45506/psn-pdf
    November 30, 2016 - Is an indication-based prescribing system in our future? November 30, 2016 ISMP Medication Safety Alert! Acute Care Edition. November 17, 2016;21:1-5. https://psnet.ahrq.gov/issue/indication-based-prescribing-system-our-future Health information technology has enhanced prescribers' ability to document the purpose o…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42085/psn-pdf
    March 13, 2013 - In-facility delirium programs as a patient safety strategy: a systematic review. March 13, 2013 Reston JT, Schoelles KM. In-facility delirium prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):375-80. doi:10.7326/0003-4819-158-5-201303051-00003. https://psnet.ah…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837154/psn-pdf
    May 18, 2022 - Survey shows room for improvement with three new best practices for hospitals. May 18, 2022 ISMP Medication Safety Alert! Acute care edition. May 5, 2022;27(9):1-5.  https://psnet.ahrq.gov/issue/survey-shows-room-improvement-three-new-best-practices-hospitals Practice changes take time to be fully incorporate…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44749/psn-pdf
    December 27, 2018 - Southern Baptist Hospital of Florida v. Charles. December 27, 2018 Fla Ct App, 1st Dist. October 28, 2015. https://psnet.ahrq.gov/issue/southern-baptist-hospital-florida-v-charles The Patient Safety and Quality Improvement Act (PSQIA) provides federal protection of adverse event reports voluntarily submitted to pa…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50561/psn-pdf
    October 16, 2019 - Patient Safety Organizations: Hospital Participation, Value, and Challenges. October 16, 2019 US Department of Health and Human Services; Office of the Inspector General, September 2019. OIG Report No. OEI-01-17-00420.  https://psnet.ahrq.gov/issue/patient-safety-organizations-hospital-participation-value-and…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44890/psn-pdf
    July 11, 2017 - The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting. July 11, 2017 Her QL, Amato MG, Seger DL, et al. The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting. J Am Med Inform Assoc. 2016;23(5):924-33. doi:10.1093/jamia/ocv181. http…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48140/psn-pdf
    July 31, 2019 - Impact of critical event checklists on anaesthetist performance in simulated operating theatre emergencies. July 31, 2019 Siddiqui A, Ng E, Burrows C, et al. Impact of Critical Event Checklists on Anaesthetist Performance in Simulated Operating Theatre Emergencies. Cureus. 2019;11(4):e4376. doi:10.7759/cureus.4376.…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44787/psn-pdf
    January 20, 2016 - Medication errors involving overrides of healthcare technology. January 20, 2016 Grissinger M. PA-PSRS Patient Saf Advis. December 2015;12:141-148. https://psnet.ahrq.gov/issue/medication-errors-involving-overrides-healthcare-technology Users often bypass alerts meant to enhance safety of medication ordering and d…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45785/psn-pdf
    September 29, 2017 - Traditions of research into interruptions in healthcare: a conceptual review. September 29, 2017 McCurdie T, Sanderson P, Aitken LM. Traditions of research into interruptions in healthcare: A conceptual review. Int J Nurs Stud. 2017;66:23-36. doi:10.1016/j.ijnurstu.2016.11.005. https://psnet.ahrq.gov/issue/traditi…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72582/psn-pdf
    December 16, 2020 - Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died. December 16, 2020 Washington, DC: Department of Veterans Affairs, Office of Inspector General; November 17, 2020. Report No 19-08542-11. https://psnet.ahrq.gov/issue/deficiencies-veterans-crisis-line-response-veteran-caller-who-died I…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46254/psn-pdf
    October 09, 2017 - Using risk stratification to reduce medical errors in cervical cancer prevention. October 9, 2017 Perkins RB, Cain JM, Feldman S. Using Risk Stratification to Reduce Medical Errors in Cervical Cancer Prevention. JAMA Intern Med. 2017;177(10):1411-1412. doi:10.1001/jamainternmed.2017.3999. https://psnet.ahrq.gov/is…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44046/psn-pdf
    August 21, 2015 - Development of an instrument to measure the unintended consequences of EHRs. August 21, 2015 Carrington JM, Gephart SM, Verran JA, et al. Development of an Instrument to Measure the Unintended Consequences of EHRs. West J Nurs Res. 2015;37(7):842-58. doi:10.1177/0193945915576083. https://psnet.ahrq.gov/issue/devel…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45146/psn-pdf
    July 18, 2016 - Driving surgical quality using operative video. July 18, 2016 O'Mahoney PRA, Yeo HL, Lange MM, et al. Driving Surgical Quality Using Operative Video. Surg Innov. 2016;23(4):337-40. doi:10.1177/1553350616643616. https://psnet.ahrq.gov/issue/driving-surgical-quality-using-operative-video Although using video documen…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46725/psn-pdf
    April 11, 2018 - Are we missing the near misses in the OR? Underreporting of safety incidents in pediatric surgery. April 11, 2018 Hamilton EC, Pham DH, Minzenmayer AN, et al. Are we missing the near misses in the OR?- underreporting of safety incidents in pediatric surgery. J Surg Res. 2018;221:336-342. doi:10.1016/j.jss.2017.08.…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48039/psn-pdf
    August 07, 2019 - Utilization of a role-based head covering system to decrease misidentification in the operating room. August 7, 2019 Rosen DA, Criser AL, Petrone AB, et al. Utilization of a Role-Based Head Covering System to Decrease Misidentification in the Operating Room. J Patient Saf. 2019;15(4):e90-e93. doi:10.1097/PTS.00000…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48159/psn-pdf
    July 31, 2019 - Fatigue in radiology: a fertile area for future research. July 31, 2019 Taylor-Phillips S, Stinton C. Fatigue in radiology: a fertile area for future research. Br J Radiol. 2019;92(1099):20190043. doi:10.1259/bjr.20190043. https://psnet.ahrq.gov/issue/fatigue-radiology-fertile-area-future-research Physician fatigu…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44702/psn-pdf
    December 16, 2015 - Alarm fatigue: impacts on patient safety. December 16, 2015 Ruskin KJ, Hueske-Kraus D. Alarm fatigue: impacts on patient safety. Curr Opin Anaesthesiol. 2015;28(6):685-690. doi:10.1097/ACO.0000000000000260. https://psnet.ahrq.gov/issue/alarm-fatigue-impacts-patient-safety Alarm fatigue is a recognized safety conce…
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