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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72581/psn-pdf
    December 16, 2020 - Dispensing Errors. December 16, 2020 Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944). November 10, December 1, 2020. https://psnet.ahrq.gov/issue/dispensing-errors Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies. Par…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843323/psn-pdf
    February 01, 2023 - Long-Term Trends of Psychotropic Drug Use in Nursing Homes. February 1, 2023 Grimm CA. Washington DC: Office of the Inspector General; Nov 2022. Report no. OEI-07-20- 00500. https://psnet.ahrq.gov/issue/long-term-trends-psychotropic-drug-use-nursing-homes Misdiagnosis can result in inappropriate medication u…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35966/psn-pdf
    January 02, 2017 - Assessing and monitoring override medications in automated dispensing devices. January 2, 2017 Kowiatek JG, Weber RJ, Skledar S, et al. Assessing and monitoring override medications in automated dispensing devices. Jt Comm J Qual Patient Saf. 2006;32(6):309-17. https://psnet.ahrq.gov/issue/assessing-and-monitoring…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47268/psn-pdf
    May 11, 2019 - Measuring shared mental models in healthcare. May 11, 2019 Gisick LM, Webster KL, Keebler JR, et al. J Patient Saf Risk Manag. 2018;23:207–219. https://psnet.ahrq.gov/issue/measuring-shared-mental-models-healthcare Shared mental models are an important element of team collaboration. This review explores the current…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42031/psn-pdf
    February 06, 2013 - Assessing diagnostic reasoning: a consensus statement summarizing theory, practice, and future needs. February 6, 2013 Ilgen JS, Humbert AJ, Kuhn G, et al. Assessing diagnostic reasoning: a consensus statement summarizing theory, practice, and future needs. Acad Emerg Med. 2012;19(12):1454-61. doi:10.1111/acem.1203…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44606/psn-pdf
    October 28, 2015 - 'Trust but verify'—five approaches to ensure safe medical apps. October 28, 2015 Wicks P, Chiauzzi E. 'Trust but verify'--five approaches to ensure safe medical apps. BMC Med. 2015;13:205. doi:10.1186/s12916-015-0451-z. https://psnet.ahrq.gov/issue/trust-verify-five-approaches-ensure-safe-medical-apps Mobile heal…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74009/psn-pdf
    October 27, 2021 - Quantifying discharge medication reconciliation errors at 2 pediatric hospitals. October 27, 2021 Morse KE, Chadwick WA, Paul W, et al. Quantifying discharge medication reconciliation errors at 2 pediatric hospitals. Pediatr Qual Saf. 2021;6(4):e436. doi:10.1097/pq9.0000000000000436. https://psnet.ahrq.gov/issue/q…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45756/psn-pdf
    December 21, 2016 - Accidental IV infusion of heparinized irrigation in the OR. December 21, 2016 ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3. https://psnet.ahrq.gov/issue/accidental-iv-infusion-heparinized-irrigation-or Accidental administration of irrigation solutions are a wrong-route error that can re…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42564/psn-pdf
    September 11, 2013 - Error rating tool to identify and analyse technical errors and events in laparoscopic surgery. September 11, 2013 Bonrath EM, Zevin B, Dedy NJ, et al. Error rating tool to identify and analyse technical errors and events in laparoscopic surgery. Br J Surg. 2013;100(8):1080-8. doi:10.1002/bjs.9168. https://psnet.ah…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46698/psn-pdf
    February 07, 2018 - Enhancing the quality and safety of the perioperative patient. February 7, 2018 Staender S, Smith A. Enhancing the quality and safety of the perioperative patient. Curr Opin Anaesthesiol. 2017;30(6):730-735. doi:10.1097/ACO.0000000000000517. https://psnet.ahrq.gov/issue/enhancing-quality-and-safety-perioperative-p…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44910/psn-pdf
    March 09, 2016 - Systematically Identified Failure Is the Route to a Successful Health System. March 9, 2016 Tepper J, Martin D, eds. Healthc Pap. 2015;15(2):4-61. https://psnet.ahrq.gov/issue/systematically-identified-failure-route-successful-health-system Identifying and addressing organizational factors that enable individual m…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838638/psn-pdf
    September 01, 2012 - Directed peer review in surgical pathology. September 1, 2012 Smith ML, Raab SS. Directed peer review in surgical pathology. Adv Anat Pathol. 2012;19(5):331-337. doi:10.1097/pap.0b013e31826661b7. https://psnet.ahrq.gov/issue/directed-peer-review-surgical-pathology Diagnostic error in pathology can result in delaye…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60989/psn-pdf
    October 07, 2020 - The accuracy of preliminary diagnoses made by paramedics - a cross-sectional comparative study. October 7, 2020 Koivulahti O, Tommila M, Haavisto E. The accuracy of preliminary diagnoses made by paramedics – a cross-sectional comparative study. Scand J Trauma Resusc Emerg Med. 2020;28(1):70. doi:10.1186/s13049-020…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45601/psn-pdf
    April 13, 2017 - Patient safety improvement interventions in children's surgery: a systematic review. April 13, 2017 Macdonald AL, Sevdalis N. Patient safety improvement interventions in children's surgery: A systematic review. J Pediatr Surg. 2017;52(3):504-511. doi:10.1016/j.jpedsurg.2016.09.058. https://psnet.ahrq.gov/issue/pat…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38842/psn-pdf
    April 18, 2011 - One-stop diagnostic breast clinics: how often are breast cancers missed? April 18, 2011 Britton P, Duffy SW, Sinnatamby R, et al. One-stop diagnostic breast clinics: how often are breast cancers missed? Br J Cancer. 2009;100(12). doi:10.1038/sj.bjc.6605082. https://psnet.ahrq.gov/issue/one-stop-diagnostic-breast-c…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50580/psn-pdf
    October 23, 2019 - Suspicious insulin injections, nearly a dozen deaths: inside an unfolding investigation at a VA hospital in West Virginia. October 23, 2019 Rein L. Washington Post. October 5, 2019. https://psnet.ahrq.gov/issue/suspicious-insulin-injections-nearly-dozen-deaths-inside-unfolding- investigation-va-hospital The Vete…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43062/psn-pdf
    September 04, 2016 - The relationship between patient safety culture and patient outcomes: a systematic review. September 4, 2016 DiCuccio MH. The Relationship Between Patient Safety Culture and Patient Outcomes: A Systematic Review. J Patient Saf. 2015;11(3):135-42. doi:10.1097/PTS.0000000000000058. https://psnet.ahrq.gov/issue/relat…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46726/psn-pdf
    January 31, 2018 - Toolkit to Promote Safe Surgery. January 31, 2018 Rockville, MD: Agency for Healthcare Research and Quality; November 2017. https://psnet.ahrq.gov/issue/toolkit-promote-safe-surgery Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on t…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45367/psn-pdf
    September 28, 2016 - How PSOs Help Health Care Organizations Improve Patient Safety Culture. September 28, 2016 Rockville, MD: Agency for Healthcare Research and Quality; April 2016. AHRQ Pub. No. 16-0026-EF. https://psnet.ahrq.gov/issue/how-psos-help-health-care-organizations-improve-patient-safety-culture Patient safety organization…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39876/psn-pdf
    July 02, 2014 - The anatomy of health care team training and the state of practice: a critical review. July 2, 2014 Weaver SJ, Lyons R, DiazGranados D, et al. The anatomy of health care team training and the state of practice: a critical review. Acad Med. 2010;85(11):1746-60. doi:10.1097/ACM.0b013e3181f2e907. https://psnet.ahrq.g…
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