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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47724/psn-pdf
    March 20, 2019 - Understanding patient safety and quality outcome data. March 20, 2019 Easter K, Tamburri LM. Understanding Patient Safety and Quality Outcome Data. Crit Care Nurse. 2018;38(6):58-66. doi:10.4037/ccn2018979. https://psnet.ahrq.gov/issue/understanding-patient-safety-and-quality-outcome-data Public reporting of safet…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43931/psn-pdf
    March 04, 2015 - Design of endoscopic retrograde cholangiopancreatography (ERCP) duodenoscopes may impede effective cleaning. March 4, 2015 FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 23, 2015. https://psnet.ahrq.gov/issue/design-endoscopic-retrograde-cholangiopancreatography-ercp- duode…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836758/psn-pdf
    March 16, 2022 - Internet of things in healthcare for patient safety: an empirical study. March 16, 2022 Yesmin T, Carter MW, Gladman AS. Internet of things in healthcare for patient safety: an empirical study. BMC Health Serv Res. 2022;22(1):278. doi:10.1186/s12913-022-07620-3. https://psnet.ahrq.gov/issue/internet-things-healthc…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846761/psn-pdf
    September 29, 2018 - Using clinical simulation to study how to improve quality and safety in healthcare. September 29, 2018 Lamé G, Dixon-Woods M. Using clinical simulation to study how to improve quality and safety in healthcare. BMJ Simul Technol Enhanc Learn. 2018;6(2):87-94. doi:10.1136/bmjstel-2018-000370. https://psnet.ahrq.gov/…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47155/psn-pdf
    October 17, 2018 - Medication errors with pediatric liquid acetaminophen after standardization of concentration and packaging improvements. October 17, 2018 Brass EP, Reynolds KM, Burnham RI, et al. Medication Errors With Pediatric Liquid Acetaminophen After Standardization of Concentration and Packaging Improvements. Acad Pediatr. …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843325/psn-pdf
    February 01, 2023 - Untenable expectations: nurses' work in the context of medication administration, error, and the organization. February 1, 2023 Hawkins SF, Morse JM. Untenable expectations: nurses' work in the context of medication administration, error, and the organization. Glob Qual Nurs Res. 2022;9:233339362211317. doi:10.117…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72584/psn-pdf
    December 16, 2020 - Hidden medication loss when using a primary administration set for small-volume intermittent infusions. December 16, 2020 ISMP Medication Safety Alert! Acute care edition. December 3, 2020;25(24). https://psnet.ahrq.gov/issue/hidden-medication-loss-when-using-primary-administration-set-small-volume- intermittent …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44872/psn-pdf
    February 12, 2016 - Reducing preventable harm in hospitals. February 12, 2016 Bornstein D. New York Times. January 26, and February 2, 2016. https://psnet.ahrq.gov/issue/reducing-preventable-harm-hospitals Discussing the importance of designing safeguards to prevent system failures that can result in patient harm, this two-part newsp…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45520/psn-pdf
    October 05, 2016 - Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic error. October 5, 2016 Foster PN, Klein JR. Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic error. J Community Hosp Intern Med Perspect. 2016;6(4):31994. doi:10.3402/jchimp.v6.31994. http…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46808/psn-pdf
    February 14, 2018 - Anesthesia medication handling needs a new vision. February 14, 2018 Grigg EB, Roesler A. Anesthesia Medication Handling Needs a New Vision. Anesth Analg. 2018;126(1):346-350. doi:10.1213/ANE.0000000000002521. https://psnet.ahrq.gov/issue/anesthesia-medication-handling-needs-new-vision Anesthesiology has been a le…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34812/psn-pdf
    March 05, 2008 - The critical incident technique. March 5, 2008 FLANAGAN JC. The critical incident technique. Psychol Bull. 1954;51(4):327-358. https://psnet.ahrq.gov/issue/critical-incident-technique This review details the background of a methodology aimed to record specific behaviors, rather than opinions or estimates, in evalu…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72778/psn-pdf
    February 24, 2021 - Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety. February 24, 2021 Mahadevan K, Cowan E, Kalsi N, et al. Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety. Open Heart. 2020;7(2). doi:10.1136/openhrt-2020-001260. h…
  13. psnet.ahrq.gov/web-mm/medication-mix-bad-worse
    March 01, 2018 - Before a drug is added to the formulary, the potential for look-alike or sound-alike error should be evaluated
  14. psnet.ahrq.gov/issue/missed-lesions-abdominal-oncologic-ct-lessons-learned-quality-assurance
    April 21, 2011 - October 4, 2011 Why Current Breast Pathology Practices Must Be Evaluated.
  15. psnet.ahrq.gov/issue/evaluation-12-strategies-obtaining-second-opinions-improve-interpretation-breast
    November 03, 2015 - April 9, 2013 Why Current Breast Pathology Practices Must Be Evaluated.
  16. psnet.ahrq.gov/issue/characteristics-and-predictors-missed-opportunities-lung-cancer-diagnosis-electronic-health
    January 19, 2012 - October 31, 2014 Why Current Breast Pathology Practices Must Be Evaluated.
  17. psnet.ahrq.gov/issue/diagnostic-errors-musculoskeletal-oncology-and-possible-mitigation-strategies
    May 01, 2013 - December 27, 2014 Why Current Breast Pathology Practices Must Be Evaluated.
  18. psnet.ahrq.gov/issue/big-dog-effect-variability-assessing-causes-error-diagnoses-patients-lung-cancer
    March 28, 2012 - April 9, 2013 Why Current Breast Pathology Practices Must Be Evaluated.
  19. psnet.ahrq.gov/issue/delayed-or-missed-diagnosis-cervical-spine-injuries
    May 05, 2010 - October 31, 2014 Why Current Breast Pathology Practices Must Be Evaluated.
  20. psnet.ahrq.gov/issue/patient-safety-leadership-academy-university-pennsylvania-first-cohorts-learning-experience
    October 04, 2011 - June 18, 2013 Why Current Breast Pathology Practices Must Be Evaluated.

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