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9961. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46831/psn-pdf
      April 18, 2018 - Guideline Summary: Medication Safety. April 18, 2018 Guideline Summary: Medication Safety. AORN J. 2018;107(4):489-494. doi:10.1002/aorn.12096. https://psnet.ahrq.gov/issue/guideline-summary-medication-safety Perioperative medication errors can result in patient harm as well as emotional distress among clinical te…

9962. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73498/psn-pdf
      July 14, 2021 - Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error July 14, 2021 ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2. https://psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error High-alert medication misadministration i…

9963. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74763/psn-pdf
      June 25, 2021 - FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing. June 25, 2021 Silver Springs, MD: US Food and Drug Administration: June 25, 2021. https://psnet.ahrq.gov/issue/fda-safety-communication-flexible-bronchoscopes-and-updated- recommendations-reprocessing Incomplete reproce…

9964. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43022/psn-pdf
      May 29, 2014 - Using simulation to improve root cause analysis of adverse surgical outcomes. May 29, 2014 Slakey DP, Simms ER, Rennie K, et al. Using simulation to improve root cause analysis of adverse surgical outcomes. Int J Qual Health Care. 2014;26(2):144-50. doi:10.1093/intqhc/mzu011. https://psnet.ahrq.gov/issue/using-sim…

9965. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43758/psn-pdf
      March 17, 2015 - A patient safety checklist for the cardiac catheterisation laboratory. March 17, 2015 Cahill TJ, Clarke SC, Simpson IA, et al. A patient safety checklist for the cardiac catheterisation laboratory. Heart. 2015;101(2):91-3. doi:10.1136/heartjnl-2014-306927. https://psnet.ahrq.gov/issue/patient-safety-checklist-card…

9966. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36917/psn-pdf
      September 01, 2011 - Analysis of deaths related to anesthesia in the period 1996-2004 from closed claims registered by the Danish Patient Insurance Association. September 1, 2011 Hove LD, Steinmetz J, Christoffersen JK, et al. Analysis of deaths related to anesthesia in the period 1996- 2004 from closed claims registered by the Danish…

9967. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36690/psn-pdf
      January 18, 2011 - The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use. January 18, 2011 Page RL, Ruscin M. The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medicatio…

9968. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74850/psn-pdf
      February 16, 2022 - Medicare penalizes dozens of hospitals it also gives five stars. February 16, 2022 Rau J. Kaiser Health News. February 8, 2022.  https://psnet.ahrq.gov/issue/medicare-penalizes-dozens-hospitals-it-also-gives-five-stars Rating systems face challenges to accurately represent the safety and quality of patient ca…

9969. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48104/psn-pdf
      August 28, 2019 - The computer will see you now. August 28, 2019 Whitaker P. New Statesman. August 2, 2019;148:38-43. https://psnet.ahrq.gov/issue/computer-will-see-you-now Artificial intelligence (AI) and advanced computing technologies can enhance clinical decision-making. Exploring the strengths and weaknesses of artificial inte…

9970. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43512/psn-pdf
      September 29, 2017 - Interruptions and multi-tasking: moving the research agenda in new directions. September 29, 2017 Westbrook JI. Interruptions and multi-tasking: moving the research agenda in new directions. BMJ Qual Saf. 2014;23(11):877-9. doi:10.1136/bmjqs-2014-003372. https://psnet.ahrq.gov/issue/interruptions-and-multi-tasking…

9971. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854634/psn-pdf
      January 01, 2024 - Elopement: evidence-based mitigation and management. October 18, 2023 Marlett JE, Vacovsky BA, Krug EA, et al. Elopement: evidence?based mitigation and management. Worldviews Evid Based Nurs. 2024;20(6):634-641. doi:10.1111/wvn.12683. https://psnet.ahrq.gov/issue/elopement-evidence-based-mitigation-and-management …

9972. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866072/psn-pdf
      June 05, 2024 - WHO Global Report on Patient Safety. June 5, 2024 Geneva, Switzerland: World Health Organization; 2024. ISBN 9789240095458. https://psnet.ahrq.gov/issue/who-global-report-patient-safety Comparative data can help to inform and motivate patient safety improvement efforts. This report uses the seven objectives of the…

9973. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41205/psn-pdf
      June 15, 2012 - Quality assessment of spontaneous triggered adverse event reports received by the Food and Drug Administration. June 15, 2012 Brajovic S, Piazza-Hepp T, Swartz L, et al. Quality assessment of spontaneous triggered adverse event reports received by the Food and Drug Administration. Pharmacoepidemiol Drug Saf. 2012;…

9974. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46458/psn-pdf
      May 30, 2018 - Development of the Huddle Observation Tool for structured case management discussions to improve situation awareness on inpatient clinical wards. May 30, 2018 Edbrooke-Childs J, Hayes J, Sharples E, et al. Development of the Huddle Observation Tool for structured case management discussions to improve situation aw…

9975. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48001/psn-pdf
      May 22, 2019 - Medicines safety in anaesthetic practice. May 22, 2019 Mackay E, Jennings J, Webber S. Medicines safety in anaesthetic practice. BJA Edu. 2019;19(5):151-157. doi:10.1016/j.bjae.2019.01.001. https://psnet.ahrq.gov/issue/medicines-safety-anaesthetic-practice Human factors affect medication delivery in the operating …

9976. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838194/psn-pdf
      September 28, 2022 - Measure Dx: implementing pathways to discover and learn from diagnostic errors. September 28, 2022 Bradford A, Shofer M, Singh H. Measure Dx: Implementing pathways to discover and learn from diagnostic errors. Int J Qual Health Care. 2022;34(3):mzac068. doi:10.1093/intqhc/mzac068. https://psnet.ahrq.gov/issue/meas…

9977. Figure 1: Medication Reconciliation Upon Admission: High Level Process Map Before Redesign | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/match/figure-1.html
      July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Figure 1: Medication Reconciliation Upon Admission: High Level Process Map Before Redesign Previous Page Next Page Table of Contents Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Med…

9978. Health and Economic Outcomes of Newborn Screening for Infantile-onset Pompe Disease | Agency for Healthcare Research and Quality
      www.ahrq.gov/priority-populations/publications/richardson-et-al-2020.html
      January 01, 2021 - Health and Economic Outcomes of Newborn Screening for Infantile-onset Pompe Disease Pompe disease is a rare condition that is identified in about 1 in 40,000 births. It occurs from a defect in the GAA gene leading to the accumulation of lysosomal glycogen and, depending on the form and severity, can result in c…

9979. Home and Community-based Services | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/index.html
      March 01, 2017 - Home and Community-based Services Home and community resources Assessing the Health and Welfare of the HCBS Population Report on developing outcome indicators to assess the 'health and welfare' of recipients of Medicaid home- and community-based services (HCBS). Environmental Scan of Measures …

9980. Symptom and needs assessment screening in oncology patients: Alternate outreach methods during COVID-19. | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/expansion-implementation-evaluation-electronic-health-record-integrated-patient/citation/symptom
      January 01, 2023 - Symptom and needs assessment screening in oncology patients: Alternate outreach methods during COVID-19. Citation Davis K , MSN, MS, MPH, Wilbur K , MSW, Metzger S , BSN, Garcia SF , PhD, Cahue S , MPH, Webster K , MA, Lylerohr M , MA, Himelhoch HL , PhD, MPH, Bilimoria K , MD, Cella D , PhD. Symptom …