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8141. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73605/psn-pdf
      August 18, 2021 - Adverse events in emergency department boarding: a systematic review. August 18, 2021 Rocha HM, Farre AGM, Santana Filho VJ. Adverse events in emergency department boarding: a systematic review. J Nurs Scholarsh. 2021;53(4):458-467. doi:10.1111/jnu.12653. https://psnet.ahrq.gov/issue/adverse-events-emergency-depar…

8142. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851924/psn-pdf
      August 02, 2023 - The things we carry: the scope and impact of second victim syndrome. August 2, 2023 Nosanov L, Elseth AJ, Maxwell J, et al. The things we carry: the scope and impact of second victim syndrome. Am J Surg. 2023;226(5):726-728. doi:10.1016/j.amjsurg.2023.06.035. https://psnet.ahrq.gov/issue/things-we-carry-scope-and-…

8143. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47855/psn-pdf
      June 19, 2019 - Medication Overload: America's Other Drug Problem. June 19, 2019 Brownlee S; Garber J. Brookline, MA: Lown Institute; 2019. https://psnet.ahrq.gov/issue/medication-overload-americas-other-drug-problem Overprescribing is a common problem that contributes to patient harm. This report examines financial, clinical, an…

8144. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838642/psn-pdf
      October 19, 2022 - Notes on healing after a missed diagnosis. October 19, 2022 Fleming EA. Notes on healing after a missed diagnosis. JAMA. 2022;328(13):1297-1298. doi:10.1001/jama.2022.15724. https://psnet.ahrq.gov/issue/notes-healing-after-missed-diagnosis Honest apology is known to support healing from medical error for clinician…

8145. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43752/psn-pdf
      January 21, 2015 - Organizational and social-psychological conditions in healthcare and their importance for patient and staff safety. A critical incident study among doctors and nurses. January 21, 2015 Eklöf M, Törner M, Pousette A. Organizational and social-psychological conditions in healthcare and their importance for patient …

8146. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72608/psn-pdf
      December 23, 2020 - Incidence of Adverse Events in Indian Health Service Hospitals. December 23, 2020 Office of the Inspector General: Washington DC; December 2020. OIG report OEI-06-17-00530. https://psnet.ahrq.gov/issue/incidence-adverse-events-indian-health-service-hospitals Challenges beset safe care delivery for indigenous …

8147. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40070/psn-pdf
      December 08, 2010 - Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine. December 8, 2010 Thyen AB, McAllister RK, Councilman LM. Epidural Pump Programming Error Leading to Inadvertent 10- Fold Dosing Error During Epidural Labor Analgesia With Ropivacaine. J Pat…

8148. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848091/psn-pdf
      April 26, 2023 - The high cost of retained surgical items. April 26, 2023 Moorehead LD. Outpatient Surgery. April 5, 2023. https://psnet.ahrq.gov/issue/high-cost-retained-surgical-items Retained surgical items (RSIs) are considered “never events” but continue to be a source of patient harm. This article discusses the various facto…

8149. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44469/psn-pdf
      September 16, 2015 - Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin. September 16, 2015 Washington, DC: VA Office of Inspector General. August 6, 2015. Report No. 15-02131-471. https://psnet.ahrq.gov/issue/unexpected-death-patient-during-treatment-multiple-medication…

8150. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36242/psn-pdf
      March 06, 2019 - Your attention please... designing effective warnings. March 6, 2019 ISMP Medication Safety Alert! Acute care edition. February 28, 2019. https://psnet.ahrq.gov/issue/your-attention-please-designing-effective-warnings Medication warnings inform providers and patients about risks associated with medication use. As w…

8151. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42580/psn-pdf
      September 11, 2013 - To disclose or not to disclose radiologic errors: should "patient-first" supersede radiologist self-interest? September 11, 2013 Berlin L. To disclose or not to disclose radiologic errors: should "patient-first" supersede radiologist self- interest? Radiology. 2013;268(1):4-7. doi:10.1148/radiol.13130193. https://…

8152. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44190/psn-pdf
      June 03, 2015 - Minimizing medical mistakes: mother's mission to reduce hospital errors. June 3, 2015 Takahara D. KDVR. May 19, 2015. https://psnet.ahrq.gov/issue/minimizing-medical-mistakes-mothers-mission-reduce-hospital-errors Parents of children who experience harm in the course of medical care serve as advocates to drive saf…

8153. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35502/psn-pdf
      May 27, 2011 - Medication errors: a prospective cohort study of hand- written and computerised physician order entry in the intensive care unit. May 27, 2011 Shulman R, Singer M, Goldstone J, et al. Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit. Cr…

8154. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43512/psn-pdf
      September 29, 2017 - Interruptions and multi-tasking: moving the research agenda in new directions. September 29, 2017 Westbrook JI. Interruptions and multi-tasking: moving the research agenda in new directions. BMJ Qual Saf. 2014;23(11):877-9. doi:10.1136/bmjqs-2014-003372. https://psnet.ahrq.gov/issue/interruptions-and-multi-tasking…

8155. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45204/psn-pdf
      September 18, 2016 - Alternative perspectives of safety in home delivered health care: a sequential exploratory mixed method study. September 18, 2016 Jones S. Alternative perspectives of safety in home delivered health care: a sequential exploratory mixed method study. J Adv Nurs. 2016;72(10):2536-46. doi:10.1111/jan.13006. https://p…

8156. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836928/psn-pdf
      April 13, 2022 - Action on patient safety can reduce health inequalities. April 13, 2022 Wade C, Malhotra AM, McGuire P, et al. Action on patient safety can reduce health inequalities. BMJ. 2022;376:e067090. doi:10.1136/bmj-2021-067090. https://psnet.ahrq.gov/issue/action-patient-safety-can-reduce-health-inequalities The role of h…

8157. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43537/psn-pdf
      October 15, 2014 - Predictors of healthcare professionals' attitudes towards family involvement in safety-relevant behaviours: a cross- sectional factorial survey study. October 15, 2014 Davis R, Savvopoulou M, Shergill R, et al. Predictors of healthcare professionals' attitudes towards family involvement in safety-relevant behaviou…

8158. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43882/psn-pdf
      February 18, 2015 - Case Studies in Patient Safety: Foundations for Core Competencies. February 18, 2015 Johnson JK, Haskell HW, Barach PR. Burlington, MA: Jones and Bartlett Learning; 2015. ISBN: 9781449681548. https://psnet.ahrq.gov/issue/case-studies-patient-safety-foundations-core-competencies Patient stories can help illustrate…

8159. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846168/psn-pdf
      March 15, 2023 - Now is the time to routinely ask patients about safety. March 15, 2023 Gandhi TK. Now Is the Time to Routinely Ask Patients About Safety. Jt Comm J Qual Patient Saf. 2023;49(4):235-236. doi:10.1016/j.jcjq.2023.01.009. https://psnet.ahrq.gov/issue/now-time-routinely-ask-patients-about-safety Safety event reporting …

8160. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44093/psn-pdf
      April 29, 2015 - South Carolina medication error bill is dangerously off target. April 29, 2015 ISMP Medication Safety Alert! Acute Care Edition. April 9, 2015;20:1,4. https://psnet.ahrq.gov/issue/south-carolina-medication-error-bill-dangerously-target This newsletter article reports on issues related to a legislation, drafted in …