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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866255/psn-pdf
    July 10, 2024 - Cyberattack led to harrowing lapses at Ascension hospitals, clinicians say. July 10, 2024 Pradhan R, Wells K. KFF Health News and Morning Edition, Michigan Public Radio: June 19, 2024. https://psnet.ahrq.gov/issue/cyberattack-led-harrowing-lapses-ascension-hospitals-clinicians-say Cybersecurity is increasingly see…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39214/psn-pdf
    January 03, 2017 - Medical trainees' formal and informal incident reporting across a five-hospital academic medical center. January 3, 2017 Logio LS, Ramanujam R. Medical trainees' formal and informal incident reporting across a five-hospital academic medical center. Jt Comm J Qual Patient Saf. 2010;36(1):36-42. https://psnet.ahrq.g…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44407/psn-pdf
    April 15, 2016 - Frequency and severity of parenteral nutrition medication errors at a large children's hospital after implementation of electronic ordering and compounding. April 15, 2016 MacKay M, Anderson C, Boehme S, et al. Frequency and Severity of Parenteral Nutrition Medication Errors at a Large Children's Hospital After Im…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837211/psn-pdf
    May 25, 2022 - 4 actions to reduce medical errors in U.S. hospitals. May 25, 2022 Toussaint JS, Segel KT. Harvard Business Review. April 20, 2022. https://psnet.ahrq.gov/issue/4-actions-reduce-medical-errors-us-hospitals The patient safety movement has had mixed results in sustaining improvement and commitment. This comment…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34644/psn-pdf
    December 23, 2008 - Medication-prescribing errors in a teaching hospital: a 9- year experience. December 23, 2008 Lesar TS, Lomaestro BM, Pohl H. Medication-prescribing errors in a teaching hospital. A 9-year experience. Arch Intern Med. 1997;157(14):1569-76. https://psnet.ahrq.gov/issue/medication-prescribing-errors-teaching-hospita…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42539/psn-pdf
    September 27, 2016 - Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. September 27, 2016 Keers RN, Williams SD, Cooke J, et al. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Saf. 2013;36(1…
  7. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.323_slideshow.ppt
    May 01, 2014 - PowerPoint Presentation Spotlight Medication Reconciliation With a Twist (or Dare We Say, a Patch?) This presentation is based on the May 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Janice Kwan, MD, Department of Medicine, University of Tor…
  8. psnet.ahrq.gov/web-mm/mid-summer-fog
    September 29, 2017 - A Mid-Summer Fog Citation Text: Braddock CH. A Mid-Summer Fog. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  9. psnet.ahrq.gov/issue/how-real-time-data-can-change-patient-safety-game
    July 07, 2021 - Commentary How real-time data can change the patient safety game. Citation Text: Diesing G. How real-time data can change the patient safety game. J AHIMA. 2020;July 1. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  10. psnet.ahrq.gov/issue/covid-19-and-healthcare-facilities-decalogue-design-strategies-resilient-hospitals
    February 23, 2022 - Commentary COVID-19 and healthcare facilities: a decalogue of design strategies for resilient hospitals. Citation Text: COVID-19 and healthcare facilities: a decalogue of design strategies for resilient hospitals. Capolongo S, Gola M, Brambilla A, et al. Acta Biomed. 2020;91(9-s):50-60.&…
  11. psnet.ahrq.gov/issue/patient-safety-developing-countries-retrospective-estimation-scale-and-nature-harm-patients
    March 23, 2011 - Study Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital. Citation Text: Wilson R, Michel P, Olsen S, et al. Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hos…
  12. psnet.ahrq.gov/issue/does-insulin-double-checking-procedure-improve-patient-safety
    April 24, 2018 - Study Does an insulin double-checking procedure improve patient safety? Citation Text: Modic MB, Albert NM, Sun Z, et al. Does an Insulin Double-Checking Procedure Improve Patient Safety? J Nurs Adm. 2016;46(3):154-60. doi:10.1097/NNA.0000000000000314. Copy Citation Format: …
  13. psnet.ahrq.gov/issue/implementing-fatigue-countermeasures-program-nurses-focus-group-analysis
    February 19, 2010 - Study Implementing a fatigue countermeasures program for nurses: a focus group analysis. Citation Text: Scott LD, Hofmeister N, Rogness N, et al. Implementing a fatigue countermeasures program for nurses: a focus group analysis. J Nurs Adm. 2010;40(5):233-40. doi:10.1097/NNA.0b013e3181d…
  14. psnet.ahrq.gov/issue/navigating-care-transitions-process-model-how-doctors-overcome-organizational-barriers-and
    February 20, 2016 - Study Navigating care transitions: a process model of how doctors overcome organizational barriers and create awareness. Citation Text: Hilligoss B, Vogus TJ. Navigating Care Transitions. Medical Care Research and Review. 2014;72(1). doi:10.1177/1077558714563170. Copy Citation Form…
  15. psnet.ahrq.gov/issue/patient-safety-culture-factors-influence-clinician-involvement-patient-safety-behaviours
    April 16, 2014 - Study Patient safety culture: factors that influence clinician involvement in patient safety behaviours. Citation Text: Wakefield JG, McLaws M-L, Whitby M, et al. Patient safety culture: factors that influence clinician involvement in patient safety behaviours. Qual Saf Health Care. 20…
  16. psnet.ahrq.gov/issue/workarounds-use-healthcare-case-study-electronic-medication-administration-system
    June 29, 2011 - Study Workarounds in the use of IS in healthcare: a case study of an electronic medication administration system. Citation Text: Yang Z, Ng B-Y, Kankanhalli A, et al. Workarounds in the use of IS in healthcare: A case study of an electronic medication administration system. Internation…
  17. psnet.ahrq.gov/issue/opioids-medicare-part-d-concerns-about-extreme-use-and-questionable-prescribing
    October 29, 2008 - Book/Report Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing. Citation Text: Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing. Office of the Inspector General. Washington, DC: US Department of Health and Human Services…
  18. psnet.ahrq.gov/issue/getting-message-quality-improvement-initiative-reduce-pages-sent-wrong-physician
    April 30, 2014 - Study Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician. Citation Text: Wong BM, Cheung M, Dharamshi H, et al. Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician. BMJ Qual Saf. 2012;21(10):85…
  19. psnet.ahrq.gov/issue/factors-associated-disclosure-medical-errors-housestaff
    January 27, 2019 - Study Factors associated with disclosure of medical errors by housestaff. Citation Text: Kronman AC, Paasche-Orlow MK, Orlander JD. Factors associated with disclosure of medical errors by housestaff. BMJ Qual Saf. 2011;21(4). doi:10.1136/bmjqs-2011-000084. Copy Citation Format: …
  20. psnet.ahrq.gov/issue/preventing-medication-errors-hospitals-through-systems-approach-and-technological-innovation
    September 11, 2019 - Commentary Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010. Citation Text: Crane J, Crane FG. Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for…

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