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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46768/psn-pdfMarch 07, 2018 - Dental Patient Safety Foundation. March 7, 2018 Dental Patient Safety Foundation; 16011 S. 108th Ave., Orland Park, IL 60467. https://psnet.ahrq.gov/issue/dental-patient-safety-foundation Dentistry, like other areas of health care, is intrinsically risky. This patient safety organization collects, analyzes, and sh… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/851662/psn-pdfJuly 26, 2023 - Mitigating bias in AI at the point of care. July 26, 2023 Decamp M, Lindvall C. Science. 2023;381(6654):150-152. https://psnet.ahrq.gov/issue/mitigating-bias-ai-point-care Computerized clinical support is vulnerable to bias due to widespread health care inequalities that feed into the systems. This article di… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44873/psn-pdfMarch 21, 2016 - Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. March 21, 2016 Cambridge, MA: CRICO Strategies; 2016. https://psnet.ahrq.gov/issue/malpractice-risks-communication-failures-2015-annual-benchmarking-report Communication failures are known to contribute to medical errors. Analyzing more … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/838144/psn-pdfSeptember 21, 2022 - Eliminating Unintentionally Retained Surgical Items - Special Report. September 21, 2022 Saver C. AORN J. 2022;116(2):111-132. https://psnet.ahrq.gov/issue/eliminating-unintentionally-retained-surgical-items-special-report Retained surgical items (RSI) are regarded as “never events” but are a persistent cause of p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37412/psn-pdfDecember 12, 2007 - The checklist. December 12, 2007 Gawande A. New Yorker. December 10, 2007:86-95. https://psnet.ahrq.gov/issue/checklist This article by bestselling author and surgeon Atul Gawande illustrates the complexity of intensive care and profiles Peter Pronovost, the Johns Hopkins intensivist and safety leader whose effort… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47569/psn-pdfApril 10, 2019 - The computerized ECG: friend and foe. April 10, 2019 Smulyan H. The Computerized ECG: Friend and Foe. Am J Med. 2019;132(2):153-160. doi:10.1016/j.amjmed.2018.08.025. https://psnet.ahrq.gov/issue/computerized-ecg-friend-and-foe Misinterpretations of critical tests can lead to diagnostic delays and patient harm. Th… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46443/psn-pdfSeptember 27, 2017 - Overtreatment in the United States. September 27, 2017 Lyu H, Xu T, Brotman D, et al. Overtreatment in the United States. PLoS One. 2017;12(9):e0181970. doi:10.1371/journal.pone.0181970. https://psnet.ahrq.gov/issue/overtreatment-united-states Overuse of medical care can lead to patient harm. In this survey study,… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/853445/psn-pdfDecember 15, 2022 - Jake Tapper shares harrowing story of daughter's near- fatal misdiagnosis. December 15, 2022 CNN. December 15, 2022. https://psnet.ahrq.gov/issue/jake-tapper-shares-harrowing-story-daughters-near-fatal-misdiagnosis Diagnostic errors are a recognized cause of preventable patient harm. This video highlights a teen’… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/48148/psn-pdfAugust 14, 2019 - Global Patient Safety: Law, Policy and Practice. August 14, 2019 Tingle J, O'Neill C, Shimwell M. New York, NY: Routledge; 2019. ISBN: 9781138052789. https://psnet.ahrq.gov/issue/global-patient-safety-law-policy-and-practice Improving patient safety is a global goal. This book covers error reduction methods used in… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47025/psn-pdfApril 11, 2018 - Chemotherapy medication errors. April 11, 2018 Weingart SN, Zhang L, Sweeney M, et al. Chemotherapy medication errors. Lancet Oncol. 2018;19(4):e191-e199. doi:10.1016/S1470-2045(18)30094-9. https://psnet.ahrq.gov/issue/chemotherapy-medication-errors Chemotherapy errors can result in serious patient harm. This revi… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837001/psn-pdfApril 27, 2022 - Final Report of the Ockenden Review. April 27, 2022 London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294. https://psnet.ahrq.gov/issue/final-report-ockenden-review Maternal and baby harm in healthcare is a sentinel event manifested by systemic failure. This report serves as the final conclusions of an i… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44639/psn-pdfSeptember 12, 2016 - Evaluation of parenteral nutrition errors in an era of drug shortages. September 12, 2016 Storey MA, Weber RJ, Besco K, et al. Evaluation of Parenteral Nutrition Errors in an Era of Drug Shortages. Nutr Clin Pract. 2016;31(2):211-7. doi:10.1177/0884533615608820. https://psnet.ahrq.gov/issue/evaluation-parenteral-n… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43304/psn-pdfJuly 02, 2014 - Finding and Preventing Patient Safety Incidents. July 2, 2014 Golden, CO: HealthGrades, Inc.; June 9, 2014. https://psnet.ahrq.gov/issue/finding-and-preventing-patient-safety-incidents Analyzing Medicare data from 2010 through 2012, this report discusses hospital efforts to prevent patient harm and estimates that … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35053/psn-pdfNovember 18, 2015 - Measured response to identified suicide risk and violence: what you need to know about psychiatric patient safety. November 18, 2015 Yeager KR, Saveanu R, Roberts AR, et al. Brief Treat Crisis Intervent. 2005;5(2):121-141 https://psnet.ahrq.gov/issue/measured-response-identified-suicide-risk-and-violence-what-you-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836870/psn-pdfApril 26, 2022 - A Conversation Among Stakeholders on Medical Malpractice. April 6, 2022 Collaborative for Accountability and Improvement. April 26, 2022. https://psnet.ahrq.gov/issue/conversation-among-stakeholders-medical-malpractice Communication and resolution programs (CRP) can improve response to patients and families a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46469/psn-pdfOctober 25, 2017 - RxAwareness. October 25, 2017 Centers for Disease Control and Prevention; CDC. https://psnet.ahrq.gov/issue/rxawareness The opioid crisis is a persisting patient safety problem. One approach to prevent misuse of opioids is to raise awareness of the addictive nature of the medication. This national campaign enlists… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39440/psn-pdfSeptember 19, 2016 - Toward understanding errors in inpatient psychiatry: a qualitative inquiry. September 19, 2016 Cullen SW, Nath SB, Marcus SC. Toward understanding errors in inpatient psychiatry: a qualitative inquiry. Psychiatr Q. 2010;81(3):197-205. doi:10.1007/s11126-010-9129-z. https://psnet.ahrq.gov/issue/toward-understanding… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72801/psn-pdfMarch 03, 2021 - Teamwork in the time of COVID-19. March 3, 2021 Takizawa PA, Honan L, Brissette D, et al. Teamwork in the time of COVID?19. FASEB Bioadv. 2020;3(3):175-181. doi:10.1096/fba.2020-00093. https://psnet.ahrq.gov/issue/teamwork-time-covid-19 The COVID-19 pandemic has led to wide-ranging changes in the health care syste… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43239/psn-pdfJune 11, 2014 - A cycle of redemption in a medical error disclosure and apology program. June 11, 2014 Carmack HJ. A Cycle of Redemption in a Medical Error Disclosure and Apology Program. Qual Health Res. 2014;24(6):860-869. https://psnet.ahrq.gov/issue/cycle-redemption-medical-error-disclosure-and-apology-program Clinicians who… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73994/psn-pdfOctober 20, 2021 - A culture of safety in EMS systems. October 20, 2021 American College of Emergency Physicians, National Association of Emergency Medical Services. Ann Emerg Med. 2021;78(3):e37-e57. https://psnet.ahrq.gov/issue/culture-safety-ems-systems-0 Emergency medical services (EMS) are often provided in stressfu…
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