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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42358/psn-pdf
    June 12, 2013 - CDC Grand Rounds: preventing unsafe injection practices in the U.S. health-care system. June 12, 2013 Prevention C for DC and. CDC grand rounds: preventing unsafe injection practices in the U.S. health-care system. MMWR Morb Mortal Wkly Rep. 2013;62(21):423-5. https://psnet.ahrq.gov/issue/cdc-grand-rounds-preventi…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41277/psn-pdf
    November 28, 2012 - AHRQ 2012 Annual Conference. November 28, 2012 Agency for Healthcare Research and Quality. September 9–12, 2012; Bethesda North Marriott Hotel & Conference Center, Bethesda, MD. https://psnet.ahrq.gov/issue/ahrq-2012-annual-conference The Agency for Healthcare Research and Quality's 2012 conference, "Moving Ahead:…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37568/psn-pdf
    February 03, 2011 - Survival from in-hospital cardiac arrest during nights and weekends. February 3, 2011 Peberdy MA, Ornato JP, Larkin L, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008;299(7):785-92. doi:10.1001/jama.299.7.785. https://psnet.ahrq.gov/issue/survival-hospital-cardiac-arrest-duri…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50762/psn-pdf
    December 18, 2019 - Mounting drug shortages delay treatments for patients with bladder cancer December 18, 2019 Tirrell M, Taylor H. CNBC. November 27, 2019. https://psnet.ahrq.gov/issue/mounting-drug-shortages-delay-treatments-patients-bladder-cancer Drug shortages are associated with increased medication errors and longer length of…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73380/psn-pdf
    June 09, 2021 - Wrong Site Surgery–Wrong Tooth Extraction. June 9, 2021 Farnborough, UK: Healthcare Safety Investigation Branch; April 2021. https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-tooth-extraction Wrong-site surgery in dentistry is a frequent and persistent never event. This report examines a case of pediatric wron…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853627/psn-pdf
    September 20, 2023 - Understanding And Addressing Pre-Hospital Diagnostic Delays. September 20, 2023 Health Affairs Forefront; May-September 2023. https://psnet.ahrq.gov/issue/understanding-and-addressing-pre-hospital-diagnostic-delays Diagnostic delays stem from both human and process failures. This series of articles examines how s…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74142/psn-pdf
    January 02, 2024 - Robert L. Wears Patient Safety Leadership Award. November 1, 2023 Regional Center at Jacksonville University, University of Florida College of Medicine – Jacksonville, FL. https://psnet.ahrq.gov/issue/robert-l-wears-patient-safety-leadership-award Inspired by the research and leadership of Dr. Robert Wears, this aw…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60563/psn-pdf
    June 03, 2020 - ‘Last responders’ seek to expand postmortem COVID testing In unexplained deaths. June 3, 2020 Andrews M. Kaiser News Network. May 19, 2020. https://psnet.ahrq.gov/issue/last-responders-seek-expand-postmortem-covid-testing-unexplained-deaths Post-mortem examination is an important tool for determining if misdiagnos…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50920/psn-pdf
    February 19, 2020 - Preeminent hospitals penalized over rates of patients’ injuries. February 19, 2020 Rau J. Kaiser Health News. January 30, 2020. https://psnet.ahrq.gov/issue/preeminent-hospitals-penalized-over-rates-patients-injuries Medicare reimbursement restrictions are a controversial stimulus to motivate hospital acquired con…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35368/psn-pdf
    July 20, 2009 - Adverse event reporting: lessons learned from 4 years of Florida office data. July 20, 2009 Coldiron BM, Fisher AH, Adelman E, et al. Adverse event reporting: lessons learned from 4 years of Florida office data. Dermatol Surg. 2005;31(9 Pt 1):1079-92; discussion 1093. https://psnet.ahrq.gov/issue/adverse-event-rep…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44492/psn-pdf
    September 23, 2015 - Teamwork in Healthcare. September 23, 2015 Fam Syst Health. 2015;33(3):175-269. https://psnet.ahrq.gov/issue/teamwork-healthcare Teamwork is a key element of patient-centered care, but evidence regarding its use in the primary care environment is limited. Articles in this special issue examine the reasons for this…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34640/psn-pdf
    March 02, 2011 - The hazards of hospitalization. March 2, 2011 Schimmel E. THE HAZARDS OF HOSPITALIZATION. Ann Intern Med. 1964;60:100-110. https://psnet.ahrq.gov/issue/hazards-hospitalization This article examines a prospective study of more than 1000 patients admitted to a university medical service. The author studied the type …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865820/psn-pdf
    May 08, 2024 - Breaking the silence on medical mistakes. May 8, 2024 Scott M. The Pulse. New York Public Radio; April 26, 2024. https://psnet.ahrq.gov/issue/breaking-silence-medical-mistakes Individuals involved in medical errors need time and support to process the incident and its consequences. This moderated podcast examines …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61055/psn-pdf
    October 21, 2020 - How administrative burdens can harm health. October 21, 2020 Herd P, Moynihan D. Health Affairs Health Policy Brief. October 2, 2020. https://psnet.ahrq.gov/issue/how-administrative-burdens-can-harm-health The crossover of health equity concepts to patient safety has emerged as a consideration for improvement. Thi…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41705/psn-pdf
    September 26, 2012 - Teamwork errors in trauma resuscitation. September 26, 2012 Sarcevic A, Marsic I, Burd RS. Teamwork Errors in Trauma Resuscitation. ACM Trans Comput Hum Interact. 2012;19(2):13:1-13:30. doi:10.1145/2240156.2240161. https://psnet.ahrq.gov/issue/teamwork-errors-trauma-resuscitation This study examines the nature of …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38619/psn-pdf
    May 07, 2018 - Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter. May 7, 2018 ISMP Medication Safety Alert! Acute Care Edition. April 23, 2009;14:1-2. https://psnet.ahrq.gov/issue/failed-check-system-chemotherapy-leads-pharmacists-no-contest-plea- involuntary-manslaughter …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34992/psn-pdf
    September 29, 2017 - Lessons from the war on cancer: the need for basic research on safety. September 29, 2017 Cook RI. J Patient Saf. 2005.1(1):7-8 https://psnet.ahrq.gov/issue/lessons-war-cancer-need-basic-research-safety The author examines parallels between President Nixon's "War on Cancer" and the work of patient safety today, p…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50739/psn-pdf
    December 11, 2019 - Medical error and moral luck. December 11, 2019 Allhoff F. Medical Error and Moral Luck. Kennedy Inst Ethics J. 2019;29(3):187-203. doi:10.1353/ken.2019.0022. https://psnet.ahrq.gov/issue/medical-error-and-moral-luck Medical error is an important problem but there has been little examination of associated conceptu…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34783/psn-pdf
    March 28, 2005 - The organizational and intraorganizational development of disasters. March 28, 2005 Turner BA. The Organizational and Interorganizational Development of Disasters. Adm Sci Q. 1976;21(3):378. doi:10.2307/2391850. https://psnet.ahrq.gov/issue/organizational-and-intraorganizational-development-disasters This article…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35133/psn-pdf
    March 11, 2011 - Parents as partners in obtaining the medication history. March 11, 2011 Porter SC, Kohane IS, Goldmann DA. Parents as partners in obtaining the medication history. J Am Med Inform Assoc. 2005;12(3):299-305. https://psnet.ahrq.gov/issue/parents-partners-obtaining-medication-history This study examined the utility o…
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