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4861. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37868/psn-pdf
      June 25, 2008 - Complexity of medication-related verbal orders. June 25, 2008 Wakefield DS, Ward MM, Groath D, et al. Complexity of medication-related verbal orders. Am J Med Qual. 2008;23(1):7-17. doi:10.1177/1062860607310922. https://psnet.ahrq.gov/issue/complexity-medication-related-verbal-orders This descriptive analysis of v…

4862. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36406/psn-pdf
      March 03, 2011 - Nature of human error: implications for surgical practice. March 3, 2011 Cuschieri A. Nature of human error: implications for surgical practice. Ann Surg. 2006;244(5):642-8. https://psnet.ahrq.gov/issue/nature-human-error-implications-surgical-practice The authors analyzed the literature to identify important compo…

4863. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39414/psn-pdf
      March 31, 2010 - Responding to large-scale testing errors. March 31, 2010 Valenstein PN, Alpern GA, Keren DF. Responding to Large-Scale Testing Errors: Table 1. Am J Clin Pathol. 2010;133(3). doi:10.1309/ajcpxlze0yynid0x. https://psnet.ahrq.gov/issue/responding-large-scale-testing-errors Using two case examples, this article analy…

4864. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36871/psn-pdf
      May 11, 2014 - Improving medication safety in the ICU: the pharmacist's role. May 11, 2014 Lee AJ, Chiao TB, Lam JT, et al. Improving Medication Safety in the ICU: The Pharmacist's Role. Hosp Pharm. 2010;42(4):337-344. doi:10.1310/hpj4204-337. https://psnet.ahrq.gov/issue/improving-medication-safety-icu-pharmacists-role The aut…

4865. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36897/psn-pdf
      August 31, 2011 - Characterization of prescribing errors in an internal medicine clinic. August 31, 2011 Devine EB, Wilson-Norton JL, Lawless NM, et al. Characterization of prescribing errors in an internal medicine clinic. Am J Health Syst Pharm. 2007;64(10):1062-70. https://psnet.ahrq.gov/issue/characterization-prescribing-errors…

4866. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37494/psn-pdf
      January 23, 2008 - Physician-Owned Specialty Hospital's Ability to Manage Medical Emergencies. January 23, 2008 Levinson DR. Washington DC: US Department of Health and Human Services, Office of Inspector General. January 2008, OEI-02-06-00310. https://psnet.ahrq.gov/issue/physician-owned-specialty-hospitals-ability-manage-medic…

4867. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39587/psn-pdf
      June 09, 2010 - Barriers and facilitators to nursing handoffs: recommendations for redesign. June 9, 2010 Welsh CA, Flanagan ME, Ebright PR. Barriers and facilitators to nursing handoffs: Recommendations for redesign. Nurs Outlook. 2010;58(3):148-154. doi:10.1016/j.outlook.2009.10.005. https://psnet.ahrq.gov/issue/barriers-and-fa…

4868. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36996/psn-pdf
      September 24, 2016 - Interruptions in a level one trauma center: a case study. September 24, 2016 Brixey J, Tang Z, Robinson DJ, et al. Interruptions in a level one trauma center: a case study. Int J Med Inform. 2008;77(4):235-41. https://psnet.ahrq.gov/issue/interruptions-level-one-trauma-center-case-study The investigators shadowed …

4869. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40318/psn-pdf
      September 12, 2012 - HealthGrades Eighth Annual Patient Safety in American Hospitals Study. September 12, 2012 Reed K, May R. Denver, CO: HealthGrades, Inc.; March 2011. https://psnet.ahrq.gov/issue/healthgrades-eighth-annual-patient-safety-american-hospitals-study This annual report used AHRQ Patient Safety Indicator data from 2007–2…

4870. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38670/psn-pdf
      November 25, 2009 - Assessing hospital safety on nights and weekends: the SWAN tool. November 25, 2009 Shulkin DJ. Assessing hospital safety on nights and weekends: the SWAN tool. J Patient Saf. 2009;5(2):75-8. doi:10.1097/PTS.0b013e3181a5db10. https://psnet.ahrq.gov/issue/assessing-hospital-safety-nights-and-weekends-swan-tool This…

4871. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42334/psn-pdf
      June 05, 2013 - What causes near-misses and how are they mitigated? June 5, 2013 Speroni KG, Fisher J, Dennis M, et al. What causes near-misses and how are they mitigated? Nursing (Brux). 2013;43(4):19-24. doi:10.1097/01.NURSE.0000427995.92553.ef. https://psnet.ahrq.gov/issue/what-causes-near-misses-and-how-are-they-mitigated Thi…

4872. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35948/psn-pdf
      August 02, 2010 - Perioperative patient safety: a multisite qualitative analysis. August 2, 2010 Chappy S. Perioperative patient safety: a multisite qualitative analysis. AORN J. 2006;83(4):871-4, 877-88, 891-7. https://psnet.ahrq.gov/issue/perioperative-patient-safety-multisite-qualitative-analysis The author identified the most …

4873. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35744/psn-pdf
      July 15, 2010 - Medication safety infrastructure in critical-access hospitals in Florida. July 15, 2010 Winterstein AG, Hartzema AG, Johns TE, et al. Medication safety infrastructure in critical-access hospitals in Florida. American Journal of Health-System Pharmacy. 2006;63(5). doi:10.2146/ajhp050345. https://psnet.ahrq.gov/issu…

4874. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36332/psn-pdf
      September 02, 2010 - Physician communication when prescribing new medications. September 2, 2010 Tarn DM, Heritage J, Paterniti DA, et al. Physician communication when prescribing new medications. Arch Intern Med. 2006;166(17):1855-1862. https://psnet.ahrq.gov/issue/physician-communication-when-prescribing-new-medications The investi…

4875. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39890/psn-pdf
      April 04, 2011 - The application of Aronson's taxonomy to medication errors in nursing. April 4, 2011 Johnson M, Young H. The application of Aronson's taxonomy to medication errors in nursing. J Nurs Care Qual. 2011;26(2):128-35. doi:10.1097/NCQ.0b013e3181f54b14. https://psnet.ahrq.gov/issue/application-aronsons-taxonomy-medicatio…

4876. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40261/psn-pdf
      March 02, 2011 - Doctors' handovers in hospitals: a literature review. March 2, 2011 Raduma-Tomàs MA, Flin R, Yule S, et al. Doctors' handovers in hospitals: a literature review. BMJ Qual Saf. 2011;20(2):128-33. doi:10.1136/bmjqs.2009.034389. https://psnet.ahrq.gov/issue/doctors-handovers-hospitals-literature-review This review ex…

4877. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36587/psn-pdf
      January 14, 2011 - The value of inking breast cores to reduce specimen mix- up. January 14, 2011 Renshaw AA, Kish R, Gould EW. The value of inking breast cores to reduce specimen mix-up. Am J Clin Pathol. 2007;127(2):271-2. https://psnet.ahrq.gov/issue/value-inking-breast-cores-reduce-specimen-mix The authors describe a tissue spec…

4878. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39474/psn-pdf
      June 27, 2011 - A model for medication safety event detection. June 27, 2011 Snyder RA, Fields W. A model for medication safety event detection. Int J Qual Health Care. 2010;22(3):179-86. doi:10.1093/intqhc/mzq014. https://psnet.ahrq.gov/issue/model-medication-safety-event-detection This AHRQ-funded work describes a model to iden…

4879. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35246/psn-pdf
      July 11, 2007 - Treatment errors in healthcare: a safety climate approach. July 11, 2007 Naveh E, Katz-Navon T, Stern Z. Treatment errors in healthcare: a safety climate approach. . Manage Sci. 2005;51(6):948-960. doi:10.1287/mnsc.1050.0372. https://psnet.ahrq.gov/issue/treatment-errors-healthcare-safety-climate-approach The auth…

4880. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36417/psn-pdf
      April 12, 2011 - Excess mortality caused by medical injury. April 12, 2011 Meurer LN, Yang H, Guse CE, et al. Excess mortality caused by medical injury. Ann Fam Med. 2006;4(5):410-6. https://psnet.ahrq.gov/issue/excess-mortality-caused-medical-injury The authors describe a state-based review of discharge diagnoses to identify medi…