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  1. 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…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46963/psn-pdf
    April 18, 2018 - A Just Culture Guide. April 18, 2018 NHS Improvement. London, UK: National Health Service; March 15, 2018. https://psnet.ahrq.gov/issue/just-culture-guide Although focusing on system failure has been highlighted as key to improving patient safety, individual behaviors must also be recognized as contributors to ris…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844757/psn-pdf
    September 11, 2019 - Diagnostic overshadowing in dentistry. September 11, 2019 Clough S, Handley P. Diagnostic overshadowing in dentistry. Br Dent J. 2019;227(4):311-315. doi:10.1038/s41415-019-0623-x. https://psnet.ahrq.gov/issue/diagnostic-overshadowing-dentistry Assumptions, communication barriers, and implicit biases can compromis…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46461/psn-pdf
    November 01, 2017 - Complications: acknowledging, managing, and coping with human error. November 1, 2017 Helo S, Moulton C-AE. Complications: acknowledging, managing, and coping with human error. Transl Androl Urol. 2017;6(4):773-782. doi:10.21037/tau.2017.06.28. https://psnet.ahrq.gov/issue/complications-acknowledging-managing-and-…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42678/psn-pdf
    February 21, 2015 - The reliability of AHRQ Common Format Harm Scales in rating patient safety events. February 21, 2015 Williams TL, Szekendi MK, Pavkovic S, et al. The reliability of AHRQ Common Format Harm Scales in rating patient safety events. J Patient Saf. 2015;11(1):52-59. doi:10.1097/PTS.0b013e3182948ef9. https://psnet.ahrq.…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41273/psn-pdf
    June 01, 2012 - Minimizing inappropriate medications in older populations: a ten-step conceptual framework. June 1, 2012 Scott IA, Gray LC, Martin J, et al. Minimizing inappropriate medications in older populations: a 10-step conceptual framework. Am J Med. 2012;125(6):529-37.e4. doi:10.1016/j.amjmed.2011.09.021. https://psnet.ah…
  7. 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…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37846/psn-pdf
    April 11, 2011 - Clinical profile of hospitalized children provided with urgent assistance from a medical emergency team. April 11, 2011 Kinney S, Tibballs J, Johnston L, et al. Clinical profile of hospitalized children provided with urgent assistance from a medical emergency team. Pediatrics. 2008;121(6):e1577-e1584. doi:10.1542/p…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43649/psn-pdf
    November 05, 2014 - How patients can improve the accuracy of their medical records. November 5, 2014 Dullabh P, Sondheimer N, Katsh E, et al. How Patients Can Improve the Accuracy of their Medical Records. eGEMs (Generating Evidence & Methods to improve patient outcomes). 2014;2(3). doi:10.13063/2327-9214.1080. https://psnet.ahrq.go…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46602/psn-pdf
    February 21, 2018 - Are quality improvement collaboratives effective? A systematic review. February 21, 2018 Wells S, Tamir O, Gray J, et al. Are quality improvement collaboratives effective? A systematic review. BMJ Qual Saf. 2018;27(3):226-240. doi:10.1136/bmjqs-2017-006926. https://psnet.ahrq.gov/issue/are-quality-improvement-coll…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41420/psn-pdf
    September 26, 2012 - Improving healthcare quality through organisational peer- to-peer assessment: lessons from the nuclear power industry. September 26, 2012 Pronovost P, Hudson DW. Improving healthcare quality through organisational peer-to-peer assessment: lessons from the nuclear power industry. BMJ Qual Saf. 2012;21(10):872-5. h…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866072/psn-pdf
    June 05, 2024 - WHO Global Report on Patient Safety. June 5, 2024 Geneva, Switzerland: World Health Organization; 2024. ISBN 9789240095458. https://psnet.ahrq.gov/issue/who-global-report-patient-safety Comparative data can help to inform and motivate patient safety improvement efforts. This report uses the seven objectives of the…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46483/psn-pdf
    October 04, 2017 - Fall Prevention in Hospitals Training Program. October 4, 2017 Rockville, MD: Agency for Healthcare Research and Quality; 2017. https://psnet.ahrq.gov/issue/fall-prevention-hospitals-training-program Falls are a primary focus of quality and patient safety improvement efforts in hospitals. This training program pro…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46243/psn-pdf
    June 05, 2019 - AHRQ Safety Program for Improving Surgical Care and Recovery. June 5, 2019 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/ahrq-safety-program-improving-surgical-care-and-recovery Patients are vulnerable to harm after surgery. This program used methods from the Comprehensive Unit- based S…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43066/psn-pdf
    December 10, 2014 - Reminder: pay attention to the appearance of your medicines. December 10, 2014 ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2. https://psnet.ahrq.gov/issue/reminder-pay-attention-appearance-your-medicines This newsletter article describes an incident involving a patient who noticed that the tabl…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46144/psn-pdf
    June 28, 2017 - Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care. June 28, 2017 Sharma M, Krishnamurthy M, Snyder R, et al. Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care. Clin Pract. 2017;7(2). doi:10.4081/cp.2017.953. https://psnet.ahrq.gov/…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41810/psn-pdf
    January 31, 2018 - Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardship. January 31, 2018 Boston University School of Public Health. Rockville, MD: Agency for Healthcare Research and Quality; September 2012. AHRQ Publication No. 120082EF. https://psnet.ahrq.gov/issue/toolkit-reduction-clostridi…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60567/psn-pdf
    June 03, 2020 - Keeping Nursing Home Residents and Staff Safe in the Era of COVID-19. June 3, 2020 National Academy of Medicine. April-June 2020. https://psnet.ahrq.gov/issue/keeping-nursing-home-residents-and-staff-safe-era-covid-19 Nursing homes are care environments that are particularly challenged by the COVID-19 pandemic. Th…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47048/psn-pdf
    April 22, 2023 - National Prescription Drug Take Back Day. April 16, 2023 Drug Enforcement Administration. April 22, 2023. https://psnet.ahrq.gov/issue/national-prescription-drug-take-back-day Removing unused medications from the home can help prevent accidental exposure to unneeded medications and limit their availability for mis…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47540/psn-pdf
    April 03, 2019 - Medication handling: towards a practical, human-centred approach. April 3, 2019 Marshall SD, Chrimes N. Medication handling: towards a practical, human-centred approach. Anaesthesia. 2019;74(3):280-284. doi:10.1111/anae.14482. https://psnet.ahrq.gov/issue/medication-handling-towards-practical-human-centred-approac…