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4521. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47594/psn-pdf
      March 17, 2023 - Prevention of perioperative medication errors. March 17, 2023 Nanji K. UpToDate. March 7, 2023. https://psnet.ahrq.gov/issue/prevention-perioperative-medication-errors Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical …

4522. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37930/psn-pdf
      July 23, 2008 - Measurement for improvement: a survey of current practice in Australian public hospitals. July 23, 2008 Brand CA, Tropea J, Ibrahim JE, et al. Measurement for improvement: a survey of current practice in Australian public hospitals. Med J Aust. 2008;189(1):35-40. https://psnet.ahrq.gov/issue/measurement-improvemen…

4523. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867769/psn-pdf
      March 12, 2025 - Lessons from Event Reports. March 12, 2025 Lessons from Event Reports. Patient Safety Authority. https://psnet.ahrq.gov/issue/lessons-event-reports Small successes can inform and motivate actions leading to sustainable, evidence-based change. This searchable collection of projects initiated in response to event re…

4524. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38658/psn-pdf
      September 27, 2017 - Development and psychometric testing of a tool to measure missed nursing care. September 27, 2017 Kalisch BJ, Williams RA. Development and psychometric testing of a tool to measure missed nursing care. J Nurs Adm. 2009;39(5):211-9. doi:10.1097/NNA.0b013e3181a23cf5. https://psnet.ahrq.gov/issue/development-and-psyc…

4525. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture | PSNet
      psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
      March 15, 2023 - Evaluating the knowledge of endotracheal cuff pressure monitoring among critical care providers by palpation

4526. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843051/psn-pdf
      February 01, 2023 - Evaluating risk factors for re-exploration due to postoperative neck hematoma after thyroid surgery:

4527. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50727/psn-pdf
      December 11, 2019 - Your diagnosis was wrong. Could doctor bias have been a factor? December 11, 2019 Glicksman E. Washington Post. November 17, 2019. https://psnet.ahrq.gov/issue/your-diagnosis-was-wrong-could-doctor-bias-have-been-factor Unconscious assumptions and biases are known contributors to poor decision-making. This news st…

4528. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37786/psn-pdf
      March 23, 2011 - A theoretical framework and competency-based approach to improving handoffs. March 23, 2011 Arora VM, Johnson JK, Meltzer DO, et al. A theoretical framework and competency-based approach to improving handoffs. Qual Saf Health Care. 2008;17(1):11-4. doi:10.1136/qshc.2006.018952. https://psnet.ahrq.gov/issue/theoret…

4529. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40660/psn-pdf
      October 04, 2011 - Incidence, nature and impact of error in surgery. October 4, 2011 Bosma E, Veen EJ, Roukema JA. Incidence, nature and impact of error in surgery. Br J Surg. 2011;98(11):1654-1659. doi:10.1002/bjs.7594. https://psnet.ahrq.gov/issue/incidence-nature-and-impact-error-surgery This study noted a 6% error rate for patie…

4530. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39724/psn-pdf
      July 28, 2010 - Prone to error: earliest steps to find cancer. July 28, 2010 Saul S. New York Times. July 19, 2010;A1. https://psnet.ahrq.gov/issue/prone-error-earliest-steps-find-cancer This newspaper article investigates diagnostic errors in breast cancer through the story of a patient who was misdiagnosed. Concern about the ac…

4531. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35734/psn-pdf
      May 04, 2015 - Benzocaine sprays marketed under different names, including Hurricaine, Topex, and Cetacaine. May 4, 2015 Food and Drug Administration; FDA; CDER; Center for Drug Evaluation and Research. https://psnet.ahrq.gov/issue/benzocaine-sprays-marketed-under-different-names-including-hurricaine- topex-and-cetacaine This F…

4532. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36883/psn-pdf
      August 31, 2011 - Voluntary review of quality of care peer review for patient safety. August 31, 2011 Stumpf PG. Voluntary review of quality of care peer review for patient safety. Best Pract Res Clin Obstet Gynaecol. 2007;21(4):557-64. https://psnet.ahrq.gov/issue/voluntary-review-quality-care-peer-review-patient-safety The autho…

4533. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40147/psn-pdf
      January 19, 2011 - Assessing the quality of patient handoffs at care transitions. January 19, 2011 Manser T, Foster S, Gisin S, et al. Assessing the quality of patient handoffs at care transitions. Qual Saf Health Care. 2010;19(6):e44. doi:10.1136/qshc.2009.038430. https://psnet.ahrq.gov/issue/assessing-quality-patient-handoffs-care…

4534. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.233_slideshow.ppt
      February 01, 2011 - Spotlight Case July 2008 Spotlight Case One Toxic Drug Is Not Like Another * * Source and Credits This presentation is based on the February 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Eric S. Holmboe, MD, American Board of Internal…

4535. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33852/psn-pdf
      January 01, 2017 - Patient Engagement in Safety January 1, 2017 Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/patient-engagement-safety Annual Perspective 2017 Background In the past 2 decades, patient engagement in safety has evolved from obscurity to maturity. The Ins…

4536. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/844756/psn-pdf
      September 18, 2019 - Emerging Concepts in Patient Safety. September 18, 2019 Shapiro FE, ed. Int Anesthesiol Clin. 2019;57:1-162. https://psnet.ahrq.gov/issue/emerging-concepts-patient-safety This publication presents patient safety concepts for anesthesia practice, including decision aids to educate and empower patients about anesthe…

4537. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36056/psn-pdf
      September 27, 2010 - Path to safety: benefits of the 2005 Patient Safety and Quality Improvement Act. September 27, 2010 McBride D, Greening A, Redmond D. Path to safety: benefits of the 2005 Patient Safety and Quality Improvement Act. Healthc Financ Manage. 2006;60(6):84-8. https://psnet.ahrq.gov/issue/path-safety-benefits-2005-patie…

4538. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35331/psn-pdf
      July 15, 2009 - Risk of adverse drug events by patient destination after hospital discharge. July 15, 2009 Triller DM, Clause SL, Hamilton RA. Risk of adverse drug events by patient destination after hospital discharge. Am J Health Syst Pharm. 2005;62(18):1883-9. https://psnet.ahrq.gov/issue/risk-adverse-drug-events-patient-desti…

4539. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40153/psn-pdf
      November 26, 2014 - The effect of workload reduction on the quality of residents' discharge summaries. November 26, 2014 Coit MH, Katz JT, McMahon GT. The effect of workload reduction on the quality of residents' discharge summaries. J Gen Intern Med. 2011;26(1):28-32. doi:10.1007/s11606-010-1465-z. https://psnet.ahrq.gov/issue/effec…

4540. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40134/psn-pdf
      February 17, 2011 - Sleep deprivation, elective surgical procedures, and informed consent. February 17, 2011 Nurok M, Czeisler CA, Lehmann LS. Sleep deprivation, elective surgical procedures, and informed consent. N Engl J Med. 2010;363(27):2577-9. doi:10.1056/NEJMp1007901. https://psnet.ahrq.gov/issue/sleep-deprivation-elective-surg…