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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39819/psn-pdf
    April 04, 2011 - Performance characteristics of a methodology to quantify adverse events over time in hospitalized patients. April 4, 2011 Sharek PJ, Parry G, Goldmann DA, et al. Performance characteristics of a methodology to quantify adverse events over time in hospitalized patients. Health Serv Res. 2011;46(2):654-78. doi:10.111…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46912/psn-pdf
    March 28, 2018 - Ignoring the Alarms: How NHS Eating Disorder Services Are Failing Patients. March 28, 2018 London, UK: Parliamentary and Health Service Ombudsman; 2017. ISBN: 9781528601344. https://psnet.ahrq.gov/issue/ignoring-alarms-how-nhs-eating-disorder-services-are-failing-patients Patients with mental health conditions fac…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843082/psn-pdf
    January 25, 2023 - Determination of unnecessary blood transfusion by comprehensive 15-hospital record review. January 25, 2023 Jadwin DF, Fenderson PG, Friedman MT, et al. Determination of unnecessary blood transfusion by comprehensive 15-hospital record review. Jt Comm J Qual Patient Saf. 2023;49(1):42-52. doi:10.1016/j.jcjq.2022.1…
  4. 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…
  5. 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 …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46216/psn-pdf
    July 12, 2017 - Physician satisfaction with transition from CPOE to paper-based prescription. July 12, 2017 Griffon N, Schuers M, Joulakian M, et al. Physician satisfaction with transition from CPOE to paper-based prescription. Int J Med Inform. 2017;103:42-48. doi:10.1016/j.ijmedinf.2017.04.007. https://psnet.ahrq.gov/issue/phys…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45212/psn-pdf
    November 23, 2016 - The impact of implementation of family-initiated escalation of care for the deteriorating patient in hospital: a systematic review. November 23, 2016 Gill FJ, Leslie GD, Marshall AP. The Impact of Implementation of Family-Initiated Escalation of Care for the Deteriorating Patient in Hospital: A Systematic Review. …
  8. 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…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42264/psn-pdf
    May 25, 2022 - Safety Considerations for Container Labels and Carton Labeling Design to Minimize Medication Errors: Guidance for Industry. May 25, 2022 Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research; May 18, 2022. https://psnet.ahrq.gov/issue/safe…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852448/psn-pdf
    January 01, 2024 - A realist synthesis of interprofessional patient safety activities and healthcare student attitudes towards patient safety. August 16, 2023 Cleary E, Bloomfield J, Frotjold A, et al. A realist synthesis of interprofessional patient safety activities and healthcare student attitudes towards patient safety. J Interp…
  11. 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…
  12. www.ahrq.gov/patient-safety/settings/hospital/match/table-5.html
    July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Table 5: Identifying Challenges and Addressing Barriers Previous Page Next Page Table of Contents Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Introducti…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46760/psn-pdf
    January 24, 2018 - Systematic evidence review of rates and burden of harm of intravenous admixture drug preparation errors in healthcare settings. January 24, 2018 Hedlund N, Beer I, Hoppe-Tichy T, et al. Systematic evidence review of rates and burden of harm of intravenous admixture drug preparation errors in healthcare settings. B…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43625/psn-pdf
    October 29, 2014 - Assessing distractors and teamwork during surgery: developing an event-based method for direct observation. October 29, 2014 Seelandt JC, Tschan F, Keller S, et al. Assessing distractors and teamwork during surgery: developing an event-based method for direct observation. BMJ Qual Saf. 2014;23(11):918-29. doi:10.11…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845657/psn-pdf
    March 08, 2023 - Dissemination and Implementation of Equity-Focused Evidence-Based Interventions in Healthcare Delivery Systems (R18). March 8, 2023 Rockville, MD: Agency for Healthcare Research and Quality. February 15, 2023. RFA-HS-23-002. https://psnet.ahrq.gov/issue/dissemination-and-implementation-equity-focused-evidence-base…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851652/psn-pdf
    July 26, 2023 - Breast cancer missed at screening; hindsight or mistakes? July 26, 2023 Hovda T, Larsen M, Romundstad L, et al. Breast cancer missed at screening; hindsight or mistakes? Eur J Radiol. 2023;165:110913. doi:10.1016/j.ejrad.2023.110913. https://psnet.ahrq.gov/issue/breast-cancer-missed-screening-hindsight-or-mistakes…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72606/psn-pdf
    December 23, 2020 - Best Practices in Developing Proprietary Names for Human Prescription Drug Products Guidance for Industry. December 23, 2020 Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research; December 2020. https://psnet.ahrq.gov/issue/best-practices-d…
  18. 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…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867136/psn-pdf
    November 13, 2024 - Detecting clinical medication errors with AI enabled wearable cameras. November 13, 2024 Chan J, Nsumba S, Wortsman M, et al. Detecting clinical medication errors with AI enabled wearable cameras. NPJ Dig Med. 2024;7(1):287. doi:10.1038/s41746-024-01295-2. https://psnet.ahrq.gov/issue/detecting-clinical-medication…
  20. 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…