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psnet.ahrq.gov/node/49830/psn-pdf
May 01, 2018 - Finally, there are problems with the safety of the environment of care on this unit.
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psnet.ahrq.gov/node/49755/psn-pdf
February 01, 2016 - Finally, because sleeping aids are so often added during a hospitalization, the appropriateness of ongoing
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psnet.ahrq.gov/web-mm/lethal-cap
December 19, 2018 - Finally, health professional schools should incorporate basic educational curricula ( 14 ) to ensure
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psnet.ahrq.gov/web-mm/pca-overdose
April 01, 2017 - Finally, in the event of an adverse clinical event possibly related to PCA usage, nothing should be discarded
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psnet.ahrq.gov/web-mm/citrate-mix
February 01, 2010 - Finally, the order entry system may be tailored to screen the patient's laboratory values (serum potassium
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psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
September 26, 2012 - Finally, in this case, patient harm was avoided by a senior clinician noticing a discrepancy between
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psnet.ahrq.gov/node/49581/psn-pdf
March 21, 2009 - Finally, Dr.
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psnet.ahrq.gov/node/45429/psn-pdf
December 19, 2016 - ONC Health IT Certification Program: Enhanced Oversight
and Accountability.
November 30, 2016
Office of the National Coordinator for Health Information Technology; ONC; Health and Human Services;
HHS.
https://psnet.ahrq.gov/issue/onc-health-it-certification-program-enhanced-oversight-and-accountability
Requiremen…
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psnet.ahrq.gov/node/45913/psn-pdf
March 01, 2017 - Simulation, mastery learning and healthcare.
March 1, 2017
Dunn W, Dong Y, Zendejas B, et al. Simulation, Mastery Learning and Healthcare. Am J Med Sci.
2017;353(2):158-165. doi:10.1016/j.amjms.2016.12.012.
https://psnet.ahrq.gov/issue/simulation-mastery-learning-and-healthcare
Simulation has been adopted as a val…
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psnet.ahrq.gov/node/43020/psn-pdf
May 29, 2014 - Handoff practices in undergraduate medical education.
May 29, 2014
Liston BW, Tartaglia KM, Evans D, et al. Handoff practices in undergraduate medical education. J Gen
Intern Med. 2014;29(5):765-9. doi:10.1007/s11606-014-2806-0.
https://psnet.ahrq.gov/issue/handoff-practices-undergraduate-medical-education
This su…
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psnet.ahrq.gov/node/43409/psn-pdf
February 25, 2015 - Evaluating iatrogenic prescribing: development of an
oncology-focused trigger tool.
February 25, 2015
Hébert G, Netzer F, Ferrua M, et al. Evaluating iatrogenic prescribing: development of an oncology-focused
trigger tool. Eur J Cancer. 2015;51(3):427-35. doi:10.1016/j.ejca.2014.12.002.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/41381/psn-pdf
May 16, 2012 - Clinical review: the hospital of the future—building
intelligent environments to facilitate safe and effective
acute care delivery.
May 16, 2012
Pickering BW, Litell JM, Herasevich V, et al. Clinical review: the hospital of the future - building intelligent
environments to facilitate safe and effective acute care …
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psnet.ahrq.gov/node/47179/psn-pdf
September 26, 2018 - Classification of patient-safety incidents in primary care.
September 26, 2018
Cooper J, Williams H, Hibbert P, et al. Classification of patient-safety incidents in primary care. Bull World
Health Organ. 2018;96(7):498-505. doi:10.2471/BLT.17.199802.
https://psnet.ahrq.gov/issue/classification-patient-safety-incide…
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psnet.ahrq.gov/node/46058/psn-pdf
October 23, 2018 - Centers for Disease Control and Prevention Guideline for
the Prevention of Surgical Site Infection, 2017.
October 23, 2018
Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline
for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8).
doi:10.100…
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psnet.ahrq.gov/node/46114/psn-pdf
June 07, 2017 - Standardizing concentrations of adult drug infusions in
Indiana.
June 7, 2017
Walroth TA, Dossett HA, Doolin M, et al. Standardizing concentrations of adult drug infusions in Indiana.
Am J Health Syst Pharm. 2017;74(7):491-497. doi:10.2146/ajhp151018.
https://psnet.ahrq.gov/issue/standardizing-concentrations-adult…
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psnet.ahrq.gov/node/43881/psn-pdf
February 11, 2015 - Cognitive Systems Engineering in Health Care.
February 11, 2015
Bisantz AM, Burns CM, Fairbanks RJ, eds. Boca Raton, FL: CRC Press; 2014. ISBN: 9781466587960.
https://psnet.ahrq.gov/issue/cognitive-systems-engineering-health-care
This publication provides information about the role of cognition in medical error. Th…
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psnet.ahrq.gov/node/43213/psn-pdf
June 04, 2014 - Back to basics: preventing surgical site infections.
June 4, 2014
Spruce L. Back to basics: preventing surgical site infections. AORN J. 2014;99(5):600-8; quiz 609-11.
doi:10.1016/j.aorn.2014.02.002.
https://psnet.ahrq.gov/issue/back-basics-preventing-surgical-site-infections
Surgical site infections are a common …
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psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
February 01, 2007 - Yes, we might use a set of digital questionnaires to help us ask all the right questions, but finally
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psnet.ahrq.gov/node/45878/psn-pdf
September 20, 2017 - Development of a trigger tool to identify adverse events
and harm in emergency medical services.
September 20, 2017
Howard IL, Bowen JM, Shaikh LAHA, et al. Development of a trigger tool to identify adverse events and
harm in Emergency Medical Services. Emerg Med J. 2017;34(6):391-397. doi:10.1136/emermed-2016-
20…
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psnet.ahrq.gov/node/43038/psn-pdf
March 05, 2014 - Missed it.
March 5, 2014
Green MJ, Rieck R. Missed it. Ann Intern Med. 2013;158(5 Pt 1):357-61. doi:10.7326/0003-4819-158-5-
201303050-00013.
https://psnet.ahrq.gov/issue/missed-it-0
This piece uses a graphic novel format to depict a story of a diagnostic error that resulted in a patient’s
death. The attention-gr…