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9681. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60227/psn-pdf
      April 15, 2020 - The next step in learning from sentinel events in healthcare. April 15, 2020 Bos K, Dongelmans DA, Greuters S, et al. The next step in learning from sentinel events in healthcare. BMJ Open Qual. 2020;9(1):e000739. doi:10.1136/bmjoq-2019-000739. https://psnet.ahrq.gov/issue/next-step-learning-sentinel-events-health…

9682. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43749/psn-pdf
      December 10, 2014 - Alarm management: first things first: using reliable data to eliminate unnecessary alarms. December 10, 2014 Vanderveen T. Patient Saf Qual Healthc. November/December 2014;11:38-40,42-45. https://psnet.ahrq.gov/issue/alarm-management-first-things-first-using-reliable-data-eliminate-unnecessary- alarms Spotlightin…

9683. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44002/psn-pdf
      March 25, 2015 - Preventing medication errors in transitions of care: a patient case approach. March 25, 2015 Johnson A, Guirguis E, Grace Y. Preventing medication errors in transitions of care: A patient case approach. J Am Pharm Assoc (2003). 2015;55(2):e264-276. doi:10.1331/JAPhA.2015.15509. https://psnet.ahrq.gov/issue/prevent…

9684. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50891/psn-pdf
      February 12, 2020 - Nurses as antimicrobial stewards: recognition, confidence, and organizational factors across nine hospitals. February 12, 2020 Monsees E, Goldman J, Vogelsmeier A, et al. Nurses as antimicrobial stewards: Recognition, confidence, and organizational factors across nine hospitals. Am J Infect Control. 2020. doi:10.1…

9685. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44749/psn-pdf
      December 27, 2018 - Southern Baptist Hospital of Florida v. Charles. December 27, 2018 Fla Ct App, 1st Dist. October 28, 2015. https://psnet.ahrq.gov/issue/southern-baptist-hospital-florida-v-charles The Patient Safety and Quality Improvement Act (PSQIA) provides federal protection of adverse event reports voluntarily submitted to pa…

9686. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43955/psn-pdf
      December 04, 2016 - For Colorado mom, story of daughter's hospital death is key to others' safety. December 4, 2016 Daley J. Colorado Public Radio. February 17, 2015. https://psnet.ahrq.gov/issue/colorado-mom-story-daughters-hospital-death-key-others-safety Patient and family stories of harm are increasingly promoted as a strategy to…

9687. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44785/psn-pdf
      January 27, 2016 - Reducing Adverse Drug Events Related to Opioids Implementation Guide. January 27, 2016 Frederickson TW. Gordon DB, De Pinto M, et al. Philadelphia, PA: Society of Hospital Medicine; 2015. https://psnet.ahrq.gov/issue/reducing-adverse-drug-events-related-opioids-implementation-guide Opioids are high-risk medication…

9688. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837431/psn-pdf
      June 15, 2022 - Anesthesiologist group says hospitals can prevent fatal errors like Vanderbilt's. June 15, 2022 Clark C. MedPage Today. June 2, 2022 https://psnet.ahrq.gov/issue/anesthesiologist-group-says-hospitals-can-prevent-fatal-errors-vanderbilts Transparency and discussion of errors is a hallmark of the culture needed to i…

9689. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40803/psn-pdf
      October 31, 2011 - Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions. October 31, 2011 van Walraven C, Jennings A, Taljaard M, et al. Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions. Can Med Assoc J. 2011;183(14). doi:1…

9690. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/855003/psn-pdf
      November 01, 2023 - The hospital ran out of her child's cancer drug. Now she's fighting to end shortages. November 1, 2023 Noguchi Y. Health Shots and All Things Considered. National Public Radio. October 23, 2023. https://psnet.ahrq.gov/issue/hospital-ran-out-her-childs-cancer-drug-now-shes-fighting-end-shortages Drug shortages…

9691. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47555/psn-pdf
      November 14, 2018 - How one hospital improved patient safety in 10 minutes a day. November 14, 2018 van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018. https://psnet.ahrq.gov/issue/how-one-hospital-improved-patient-safety-10-minutes-day Aviation continues to provide inspiration for patient safety innovation. This commentar…

9692. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42823/psn-pdf
      December 18, 2013 - The Orthopaedic Error Index: development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach. December 18, 2013 Panesar SS, Netuveli G, Carson-Stevens A, et al. The orthopaedic error index: development and application of a novel nationa…

9693. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837422/psn-pdf
      June 15, 2022 - Reported clinical incidents of children with intellectual disability: a qualitative analysis. June 15, 2022 Ong N, Mimmo L, Barnett D, et al. Reported clinical incidents of children with intellectual disability: a qualitative analysis. Dev Med Child Neurol. 2022;64(11):1359-1365. doi:10.1111/dmcn.15262. https://ps…

9694. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43866/psn-pdf
      January 28, 2015 - Inside Canada's secret world of medical error: 'There is a lot of lying, there's a lot of cover-up.' January 28, 2015 Blackwell T. https://psnet.ahrq.gov/issue/inside-canadas-secret-world-medical-error-there-lot-lying-theres-lot-cover Reporting on the lack of transparency around medical errors in Canada, this news…

9695. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47872/psn-pdf
      March 27, 2019 - Overview of the Environmental Scan of Primary Care- Based Effort To Reduce Readmissions. March 27, 2019 Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF. https://psnet.ahrq.gov/issue/overview-environmental-scan-primar…

9696. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866318/psn-pdf
      July 17, 2024 - Methods to increase reliability in quality improvement projects. July 17, 2024 Lenk MA, LaMantia S, Oehler J, et al. Methods to increase reliability in quality improvement projects. Hosp Pediatr. 2024;14(8):e372-e377. doi:10.1542/hpeds.2023-007340. https://psnet.ahrq.gov/issue/methods-increase-reliability-quality-…

9697. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46895/psn-pdf
      March 14, 2018 - Rapid response teams: what's the latest? March 14, 2018 Jackson SA. Rapid response teams: What's the latest? Nursing (Brux). 2017;47(12):34-41. doi:10.1097/01.NURSE.0000526885.10306.21. https://psnet.ahrq.gov/issue/rapid-response-teams-whats-latest Rapid response systems are an established strategy to prevent in-h…

9698. The Unfamiliar Catheter | PSNet
      psnet.ahrq.gov/web-mm/unfamiliar-catheter
      November 01, 2006 - The Unfamiliar Catheter Citation Text: Swayze SC, James A. The Unfamiliar Catheter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

9699. Autopsy Revelation | PSNet
      psnet.ahrq.gov/web-mm/autopsy-revelation
      December 01, 2007 - Autopsy Revelation Citation Text: Shojania KG. Autopsy Revelation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

9700. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33668/psn-pdf
      May 01, 2008 - In Conversation with…David W. Bates, MD, MSc May 1, 2008 In Conversation with…David W. Bates, MD, MSc. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc Editor's note: Dr. David Bates is a Professor at Harvard Medical School, Medical Director of Clinical and Quality …