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8081. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46727/psn-pdf
      August 21, 2021 - Alliance for Innovation on Maternal Health. August 21, 2021 American College of Obstetricians and Gynecologists. https://psnet.ahrq.gov/issue/alliance-innovation-maternal-health This website provides information from a multidisciplinary collaboration whose mission was to support safe health care for pregnant and p…

8082. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47336/psn-pdf
      March 04, 2019 - "Saying sorry": some strategies for effective apology within the workplace. March 4, 2019 Cleary M, Lees D, Lopez V. "Saying sorry": some strategies for effective apology within the workplace. Issues Ment Health Nurs. 2018;39(11):980-982. doi:10.1080/01612840.2018.1507571. https://psnet.ahrq.gov/issue/saying-sorry…

8083. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72865/psn-pdf
      March 17, 2021 - 5 pandemic mistakes we keep repeating. We can learn from our failures. March 17, 2021 Zeynep Tufekci. The Atlantic. February 26, 2021 https://psnet.ahrq.gov/issue/5-pandemic-mistakes-we-keep-repeating-we-can-learn-our-failures Failures in communication have impacts on patients, teams, organizations and society. Th…

8084. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46160/psn-pdf
      June 07, 2017 - ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults. June 7, 2017 Horsham, PA: Institute for Safe Medication Practices; May 2017. https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-subcutaneous-insulin-use-adults Insulin is a widely used medication that can contribute to serious patien…

8085. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47827/psn-pdf
      February 27, 2019 - Improving Usability, Safety and Patient Outcomes With Health Information Technology. February 27, 2019 Lau F, Bartle-Clar JA, Bliss G, et al, eds. Stud Health Technol Inform. 2019;257:1-539. ISBN: 9781614999508. https://psnet.ahrq.gov/issue/improving-usability-safety-and-patient-outcomes-health-information-technol…

8086. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44272/psn-pdf
      November 06, 2015 - Technology, cognition and error. November 6, 2015 Coiera E. Technology, cognition and error. BMJ Qual Saf. 2015;24(7):417-22. doi:10.1136/bmjqs-2014- 003484. https://psnet.ahrq.gov/issue/technology-cognition-and-error Providers and policymakers have raised concerns about risks associated with health information t…

8087. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837024/psn-pdf
      May 04, 2022 - The potential for leveraging machine learning to filter medication alerts. May 4, 2022 Liu S, Kawamoto K, Del Fiol G, et al. The potential for leveraging machine learning to filter medication alerts. J Am Med Inform Assoc. 2022;29(5):891-899. doi:10.1093/jamia/ocab292. https://psnet.ahrq.gov/issue/potential-levera…

8088. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36620/psn-pdf
      January 14, 2024 - ISMP's List of High-Alert Medications in Acute Care Settings. January 14, 2024 Horsham, PA; Institute for Safe Medication Practices: 2024. https://psnet.ahrq.gov/issue/ismps-list-high-alert-medications-acute-care-settings This fact sheet lists medications with a high risk of causing significant harm to patients wh…

8089. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46444/psn-pdf
      December 19, 2017 - Nil per os orders for imaging: a teachable moment. December 19, 2017 Wickerham AL, Schultz EJ, Lewine EB. Nil per Os Orders for Imaging: A Teachable Moment. JAMA Intern Med. 2017;177(11):1670-1671. doi:10.1001/jamainternmed.2017.3943. https://psnet.ahrq.gov/issue/nil-os-orders-imaging-teachable-moment Patients are…

8090. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60604/psn-pdf
      June 17, 2020 - The limits of current A.I. in health care: patient safety policing in hospitals. June 17, 2020 Furrow BR. NE Univ Law Rev. 2020;12(1):1-55. https://psnet.ahrq.gov/issue/limits-current-ai-health-care-patient-safety-policing-hospitals Artificial intelligence (AI) has the potential to improve the use of big data to e…

8091. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46189/psn-pdf
      September 29, 2017 - Countering cognitive biases in minimising low value care. September 29, 2017 Scott IA, Soon J, Elshaug AG, et al. Countering cognitive biases in minimising low value care. Med J Aust. 2017;206(9):407-411. https://psnet.ahrq.gov/issue/countering-cognitive-biases-minimising-low-value-care Heuristics and cognitive bi…

8092. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40729/psn-pdf
      October 04, 2011 - Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008. October 4, 2011 Cassidy CJ, Smith AF, Arnot-Smith J. Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning Syste…

8093. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48055/psn-pdf
      June 26, 2019 - Prevention of opioid overdose. June 26, 2019 Babu KM, Brent J, Juurlink DN. Prevention of opioid overdose.  N Engl J Med. 2019;380(23):2246-2255. doi:10.1056/NEJMra1807054. https://psnet.ahrq.gov/issue/prevention-opioid-overdose Reducing patient harm associated with the use of opioids to manage pain is a patient s…

8094. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47751/psn-pdf
      May 01, 2019 - Heart Failure: The Decline of a Historic Transplant Program. January 30, 2019 Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica. May 2018-May 2019. https://psnet.ahrq.gov/issue/heart-failure-decline-historic-transplant-program This news investigation chronicles a series of incidents in a transplant progra…

8095. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50425/psn-pdf
      September 04, 2019 - Why doctors still offer treatments that may not help. September 4, 2019 Frakt A. New York Times. August 26, 2019. https://psnet.ahrq.gov/issue/why-doctors-still-offer-treatments-may-not-help The slow adoption of improvement innovations is a persistent challenge to high-quality and safe patient care. This newspaper…

8096. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42050/psn-pdf
      January 07, 2015 - The association between frequency of self-reported medical errors and anesthesia trainee supervision: a survey of United States anesthesiology residents-in- training. January 7, 2015 De Oliveira GS, Rahmani R, Fitzgerald PC, et al. The association between frequency of self-reported medical errors and anesthesia t…

8097. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43150/psn-pdf
      April 30, 2014 - Children's Hospital investigated five patient deaths from deadly fungal disease in 2009. April 30, 2014 Duffy J, Harris J, Gade L, et al. Mucormycosis outbreak associated with hospital linens. The Pediatric infectious disease journal. 2014;33(5):472-6. doi:10.1097/INF.0000000000000261. https://psnet.ahrq.gov/issue…

8098. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44333/psn-pdf
      July 15, 2015 - One hospital's initiatives to encourage safe opioid use. July 15, 2015 Surprise JK, Simpson MH. One Hospital's Initiatives to Encourage Safe Opioid Use. J Infus Nurs. 2015;38(4):278-83. doi:10.1097/NAN.0000000000000110. https://psnet.ahrq.gov/issue/one-hospitals-initiatives-encourage-safe-opioid-use This commentar…

8099. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46524/psn-pdf
      October 18, 2017 - Pressure Injury Prevention in Hospitals Training Program. October 18, 2017 Rockville, MD: Agency for Healthcare Research and Quality; September 2017. https://psnet.ahrq.gov/issue/pressure-injury-prevention-hospitals-training-program Pressure ulcers are a common hospital-acquired condition that can lead to patient h…

8100. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47766/psn-pdf
      March 27, 2019 - Advancing the Safety of Acute Pain Management. March 27, 2019 Boston, MA: Institute for Healthcare Improvement; 2019. https://psnet.ahrq.gov/issue/advancing-safety-acute-pain-management Pain management has emerged as a complex safety concern. This report discusses four organizational prerequisites to improve pain …