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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50664/psn-pdf
    November 13, 2019 - Drug Shortages: Root Causes and Potential Solutions. November 13, 2019 Drug Shortage Task Force. Silver Spring, MD: US Food and Drug Administration; 2020. https://psnet.ahrq.gov/issue/drug-shortages-root-causes-and-potential-solutions Drug shortages result from a variety of systemic failures. This report identifies…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41893/psn-pdf
    January 09, 2013 - Counting matters: lessons from the root cause analysis of a retained surgical item. January 9, 2013 Agrawal A. Counting matters: lessons from the root cause analysis of a retained surgical item. Jt Comm J Qual Patient Saf. 2012;38(12):566-574. https://psnet.ahrq.gov/issue/counting-matters-lessons-root-cause-analys…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36041/psn-pdf
    June 21, 2006 - Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols. June 21, 2006 Rampersaud YR; Moro ER; Neary MA; White K; Lewis SJ; Massicotte EM; Fehlings MG. https://psnet.ahrq.gov/issue/intraoperative-adverse-…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36429/psn-pdf
    March 28, 2011 - Governing the surgical count through communication interactions: implications for patient safety. March 28, 2011 Riley R, Manias E, Polglase A. Governing the surgical count through communication interactions: implications for patient safety. Qual Saf Health Care. 2006;15(5):369-374. https://psnet.ahrq.gov/issue/go…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41164/psn-pdf
    June 10, 2018 - Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. February 9, 2012;17:1-4. https://psnet.ahrq.gov/issue/results-ismp-survey-high-alert-medications-differences-between-nursing…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36499/psn-pdf
    January 07, 2011 - Retrospective analysis of medication incidents reported using an on-line reporting system. January 7, 2011 Ashcroft DM, Cooke J. Retrospective analysis of medication incidents reported using an on-line reporting system. Pharmacy World & Science. 2006;28(6). doi:10.1007/s11096-006-9040-8. https://psnet.ahrq.gov/iss…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39814/psn-pdf
    January 28, 2015 - Patient safety for global health - developing safe, effective and accessible technologies. January 28, 2015 Qual Saf Health Care. 2010;19(suppl 2):i1-i47. https://psnet.ahrq.gov/issue/patient-safety-global-health-developing-safe-effective-and-accessible- technologies This supplement provides the conclusions of wo…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43086/psn-pdf
    March 26, 2014 - International Comparisons: A Focus on Quality of Care. March 26, 2014 Ottawa, ON: Canadian Institute for Health Information; January 23, 2014. https://psnet.ahrq.gov/issue/international-comparisons-focus-quality-care This report compared the quality of care in Canada with 34 other countries to identify areas in whi…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43864/psn-pdf
    January 28, 2015 - Starter Kit for Alarm Fatigue. January 28, 2015 National Association of Clinical Nurse Specialists; NACNS. https://psnet.ahrq.gov/issue/starter-kit-alarm-fatigue Alarm fatigue has been identified as a serious problem that affects the safety of nursing care. This toolkit provides checklists, resources, and implemen…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35426/psn-pdf
    September 15, 2009 - Medical malpractice in the People's Republic of China: the 2002 regulation on the handling of medical accidents. September 15, 2009 Harris DM, Wu C-C. Medical malpractice in the People's Republic of China: the 2002 Regulation on the Handling of Medical Accidents. J Law Med Ethics. 2005;33(3):456-77. https://psnet.…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36759/psn-pdf
    August 10, 2011 - Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. August 10, 2011 Bressler B, Paszat LF, Chen Z, et al. Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. Gastroenterology. 2007;132(1):96-10…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46117/psn-pdf
    May 10, 2017 - Deep learning is a black box, but health care won't mind. May 10, 2017 Brouillette M. MIT Technol Rev. April 27, 2017. https://psnet.ahrq.gov/issue/deep-learning-black-box-health-care-wont-mind Artificial intelligence can support diagnostic decision-making. This magazine article reports on the use of algorithms to…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39160/psn-pdf
    December 09, 2009 - Information-gathering patterns associated with higher rates of diagnostic error. December 9, 2009 Delzell JE, Chumley H, Webb R, et al. Information-gathering patterns associated with higher rates of diagnostic error. Adv Health Sci Educ Theory Pract. 2009;14(5):697-711. doi:10.1007/s10459-009-9152-8. https://psnet…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836867/psn-pdf
    April 06, 2022 - Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence. April 6, 2022 Houston TX;  Baylor College of Medicine: 2022. https://psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence Assessment can identify the current state of a process or program to reveal ar…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41444/psn-pdf
    June 13, 2012 - Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities. June 13, 2012 Washington, DC: VA Office of Inspector General; April 20, 2012. Report No. 12-00956-159. https://psnet.ahrq.gov/issue/evaluation-registered-nurse-competency-processes-veterans-health- administration-faci…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34823/psn-pdf
    April 06, 2011 - Use of medical emergency team (MET) responses to detect medical errors. April 6, 2011 Braithwaite RS, Devita MA, Mahidhara R, et al. Use of medical emergency team (MET) responses to detect medical errors. Qual Saf Health Care. 2004;13(4):255-259. https://psnet.ahrq.gov/issue/use-medical-emergency-team-met-response…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40115/psn-pdf
    January 05, 2011 - Infection control hazards and near misses reported by nursing students. January 5, 2011 Geller NF, Bakken S, Currie LM, et al. Infection control hazards and near misses reported by nursing students. Am J Infect Control. 2010;38(10):811-6. doi:10.1016/j.ajic.2010.06.001. https://psnet.ahrq.gov/issue/infection-contr…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40439/psn-pdf
    July 31, 2012 - Medication error identification rates by pharmacy, medical, and nursing students. July 31, 2012 Warholak TL, Queiruga C, Roush R, et al. Medication error identification rates by pharmacy, medical, and nursing students. Am J Pharm Educ. 2011;75(2):24. https://psnet.ahrq.gov/issue/medication-error-identification-rat…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37607/psn-pdf
    May 02, 2018 - USA Today news series: clarifying the issues and embracing community pharmacy safety. May 2, 2018 ISMP Medication Safety Alert! Acute care edition. February 28, 2008. https://psnet.ahrq.gov/issue/usa-today-news-series-clarifying-issues-and-embracing-community-pharmacy- safety This article contextualizes a recent …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43433/psn-pdf
    October 01, 2014 - Medical error and systems of signaling: conceptual and linguistic definition. October 1, 2014 Smorti A, Cappelli F, Zarantonello R, et al. Medical error and systems of signaling: conceptual and linguistic definition. Intern Emerg Med. 2014;9(6):681-8. doi:10.1007/s11739-014-1108-1. https://psnet.ahrq.gov/issue/med…
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