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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/34894/psn-pdfJuly 10, 2008 - Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. July 10, 2008 Lau DT, Kasper JD, Potter DEB, et al. Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. A… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44651/psn-pdfDecember 09, 2015 - Measurement of diagnostic errors is a key first step to their reduction. December 9, 2015 Singh H. National Quality Measures Expert Commentaries. November 23, 2015. https://psnet.ahrq.gov/issue/measurement-diagnostic-errors-key-first-step-their-reduction Recently, diagnostic error has garnered much discussion and … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46752/psn-pdfJuly 19, 2018 - Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study. July 19, 2018 Westbrook JI, Raban MZ, Walter SR, et al. Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72735/psn-pdfFebruary 10, 2021 - Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri. February 10, 2021 Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 5, 2021. Report No. 20-01521-48. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866171/psn-pdfJune 19, 2024 - Keeping Children and Young People with Mental Health Needs Safe: the Design of the Paediatric Ward. June 19, 2024 Dorset, UK: Health Services Safety Investigations Body; May 2024 https://psnet.ahrq.gov/issue/keeping-children-and-young-people-mental-health-needs-safe-design- paediatric-ward Acute mental health car… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46582/psn-pdfFebruary 14, 2018 - Technological distractions—part 1 and part 2. February 14, 2018 Kane-Gill SL, O'Connor MF, Rothschild JM, et al. Technologic Distractions (Part 1): Summary of Approaches to Manage Alert Quantity With Intent to Reduce Alert Fatigue and Suggestions for Alert Fatigue Metrics. Crit Care Med. 2017;45(9):1481-1488. doi:1… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44924/psn-pdfApril 15, 2016 - Assessment of fidelity in interventions to improve hand hygiene of healthcare workers: a systematic review. April 15, 2016 Musuuza JS, Barker A, Ngam C, et al. Assessment of Fidelity in Interventions to Improve Hand Hygiene of Healthcare Workers: A Systematic Review. Infect Control Hosp Epidemiol. 2016;37(5):567-75… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73222/psn-pdfMay 05, 2021 - Fatal mistakes: why do ten-fold medication errors in children keep happening? May 5, 2021 Parry C. The Pharmaceutical Journal. April 22 2021. https://psnet.ahrq.gov/issue/fatal-mistakes-why-do-ten-fold-medication-errors-children-keep-happening Weight-based prescribing in children harbors challenges to accura… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/861294/psn-pdfJanuary 24, 2024 - Shining a glaring light on surgery: technology that records every move aims to improve safety. January 24, 2024 Freyer FJ. Boston Globe. January 13, 2024. https://psnet.ahrq.gov/issue/shining-glaring-light-surgery-technology-records-every-move-aims-improve- safety The surgical black box uses cameras and microphon… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/844748/psn-pdfFebruary 15, 2023 - 'They were his best shot. And they failed to help’: why did EMS workers neglect Tyre Nichols? February 15, 2023 Renault M. STAT. February 6, 2023. https://psnet.ahrq.gov/issue/they-were-his-best-shot-and-they-failed-help-why-did-ems-workers-neglect- tyre-nichols Emergent care situations are vulnerable to a range … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45588/psn-pdfJanuary 23, 2017 - Computer-assisted process modeling to enhance intraoperative safety in cardiac surgery. January 23, 2017 Tarola CL, Quin JA, Haime ME, et al. Computer-Assisted Process Modeling to Enhance Intraoperative Safety in Cardiac Surgery. JAMA Surg. 2016;151(12):1183-1186. doi:10.1001/jamasurg.2016.2839. https://psnet.ahrq… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40022/psn-pdfJune 09, 2011 - Patient safety begins with proper planning: a quantitative method to improve hospital design. June 9, 2011 Birnbach DJ, Nevo I, Scheinman SR, et al. Patient safety begins with proper planning: a quantitative method to improve hospital design. Qual Saf Health Care. 2010;19(5):462-5. doi:10.1136/qshc.2008.031013. h… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/855438/psn-pdfNovember 15, 2023 - Intravenous (IV) push medications – bridging the gap between education and clinical practice. November 15, 2023 ISMP Medication Safety Alert! Acute Care. November 2, 2023;28(22):1-4. https://psnet.ahrq.gov/issue/intravenous-iv-push-medications-bridging-gap-between-education-and-clinical- practice Intravenous… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46057/psn-pdfSeptember 24, 2017 - Narrative feedback from OR personnel about the safety of their surgical practice before and after a surgical safety checklist intervention. September 24, 2017 Alidina S, Hur H-C, Berry WR, et al. Narrative feedback from OR personnel about the safety of their surgical practice before and after a surgical safety che… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38534/psn-pdfJanuary 31, 2013 - Health care information technology vendors' "hold harmless" clause: implications for patients and clinicians. January 31, 2013 Koppel R, Kreda D. Health care information technology vendors' "hold harmless" clause: implications for patients and clinicians. JAMA. 2009;301(12):1276-8. doi:10.1001/jama.2009.398. https… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46402/psn-pdfMarch 20, 2018 - Safety events in pediatric out-of-hospital cardiac arrest. March 20, 2018 Hansen M, Eriksson C, Skarica B, et al. Safety events in pediatric out-of-hospital cardiac arrest. Am J Emerg Med. 2018;36(3):380-383. doi:10.1016/j.ajem.2017.08.028. https://psnet.ahrq.gov/issue/safety-events-pediatric-out-hospital-cardiac-a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47967/psn-pdfMay 01, 2019 - The Harvard Medical Practice Study trigger system performance in deceased patients. May 1, 2019 Klein DO, Rennenberg RJMW, Koopmans RP, et al. The Harvard medical practice study trigger system performance in deceased patients. BMC Health Serv Res. 2019;19(1):16. doi:10.1186/s12913-018-3839-6. https://psnet.ahrq.go… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/48036/psn-pdfJuly 10, 2019 - Can positivity promote safety? Psychological capital development combats cynicism and unsafe behavior. July 10, 2019 Stratman JL, Youssef-Morgan CM. Can positivity promote safety? Psychological capital development combats cynicism and unsafe behavior. Safety Sci. 2019;116:13-25. doi:10.1016/j.ssci.2019.02.031. htt… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41801/psn-pdfOctober 31, 2012 - First year with WHO Surgical Safety Checklist in 7148 otorhinolaryngological operations: use and user attitudes. October 31, 2012 Helmiö P, Takala A, Aaltonen L-M, et al. First year with WHO Surgical Safety Checklist in 7148 otorhinolaryngological operations: use and user attitudes. Clin Otolaryngol. 2012;37(4):30… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73522/psn-pdfJuly 21, 2021 - Federal speech rulings may embolden health care workers to call out safety issues. July 21, 2021 Meyer H. Kaiser Health News. July 9, 2021. https://psnet.ahrq.gov/issue/federal-speech-rulings-may-embolden-health-care-workers-call-out-safety- issues Whistleblower protections are a key component to raising awarenes…
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