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5341. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36127/psn-pdf
      September 29, 2010 - Fatality involving vinblastine overdose as a result of a complex medical error. September 29, 2010 K?ys M, Konopka T, Scis?owski M, et al. Fatality involving vinblastine overdose as a result of a complex medical error. Cancer Chemother Pharmacol. 2007;59(1):89-95. https://psnet.ahrq.gov/issue/fatality-involving-vi…

5342. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42561/psn-pdf
      October 09, 2013 - Defining technical errors in laparoscopic surgery: a systematic review. October 9, 2013 Bonrath EM, Dedy NJ, Zevin B, et al. Defining technical errors in laparoscopic surgery: a systematic review. Surg Endosc. 2013;27(8):2678-91. doi:10.1007/s00464-013-2827-5. https://psnet.ahrq.gov/issue/defining-technical-errors…

5343. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37964/psn-pdf
      June 29, 2011 - Impact of miscommunication in medical dispute cases in Japan. June 29, 2011 Aoki N, Uda K, Ohta S, et al. Impact of miscommunication in medical dispute cases in Japan. Int J Qual Health Care. 2008;20(5):358-62. doi:10.1093/intqhc/mzn028. https://psnet.ahrq.gov/issue/impact-miscommunication-medical-dispute-cases-ja…

5344. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39882/psn-pdf
      January 19, 2011 - Incidence and types of non-ideal care events in an emergency department. January 19, 2011 Hall KK, Schenkel SM, Hirshon JM, et al. Incidence and types of non-ideal care events in an emergency department. Qual Saf Health Care. 2010;19 Suppl 3:i20-5. doi:10.1136/qshc.2010.040246. https://psnet.ahrq.gov/issue/inciden…

5345. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42310/psn-pdf
      June 10, 2018 - Administering a saline flush "site unseen" can lead to a wrong route error. June 10, 2018 ISMP Medication Safety Alert! Acute care edition. May 16, 2013;18:1-3. https://psnet.ahrq.gov/issue/administering-saline-flush-site-unseen-can-lead-wrong-route-error Describing a tubing misconnection error, this newsletter id…

5346. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35469/psn-pdf
      January 21, 2011 - Neurologic patient safety: an in-depth study of malpractice claims. January 21, 2011 Glick TH, Cranberg LD, Hanscom RB, et al. Neurologic patient safety: an in-depth study of malpractice claims. Neurology. 2005;65(8):1284-6. https://psnet.ahrq.gov/issue/neurologic-patient-safety-depth-study-malpractice-claims The…

5347. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34623/psn-pdf
      January 28, 2015 - Australian Commission on Safety and Quality in Health Care. January 28, 2015 Australian Commission for Safety and Quality in Health Care. https://psnet.ahrq.gov/issue/australian-commission-safety-and-quality-health-care Established in January 2006, the Commission leads and coordinates improvements in safety and qu…

5348. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39780/psn-pdf
      January 04, 2017 - The First Annual HealthGrades Pediatric Patient Safety in American Hospitals Study. January 4, 2017 Reed K, May R. Golden, CO: Health Grades, Inc; 2010. https://psnet.ahrq.gov/issue/first-annual-healthgrades-pediatric-patient-safety-american-hospitals-study This report analyzed Agency for Healthcare Research and Q…

5349. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40157/psn-pdf
      January 19, 2011 - Instrument readiness: an important link to patient safety. January 19, 2011 McNamara SA. Instrument readiness: an important link to patient safety. AORN J. 2011;93(1):160-4. doi:10.1016/j.aorn.2010.09.027. https://psnet.ahrq.gov/issue/instrument-readiness-important-link-patient-safety This commentary reviews steps…

5350. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40781/psn-pdf
      September 14, 2011 - Reducing the incidence of retained surgical instrument fragments. September 14, 2011 Reece M, Troeleman ND, McGowan JE, et al. Reducing the incidence of retained surgical instrument fragments. AORN J. 2011;94(3):301-4. doi:10.1016/j.aorn.2011.05.014. https://psnet.ahrq.gov/issue/reducing-incidence-retained-surgica…

5351. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37736/psn-pdf
      April 30, 2008 - Causes of near misses in critical care of neonates and children. April 30, 2008 Tourgeman-Bashkin O, Shinar D, Zmora E. Causes of near misses in critical care of neonates and children. Acta Paediatr. 2008;97(3):299-303. doi:10.1111/j.1651-2227.2007.00616.x. https://psnet.ahrq.gov/issue/causes-near-misses-critical-…

5352. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38338/psn-pdf
      January 14, 2009 - Implementation of patient safety rounds in a children's hospital. January 14, 2009 Yee PL, Edwards ML, Dixon JL, et al. Implementation of patient safety rounds in a children's hospital. Nurs Adm Q. 2009;33(1):48-53. doi:10.1097/01.NAQ.0000343348.93537.41. https://psnet.ahrq.gov/issue/implementation-patient-safety-…

5353. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73548/psn-pdf
      July 27, 2021 - Diagnostic Errors in Primary Care. July 27, 2021 Betsy Lehman Center for Patient Safety. https://psnet.ahrq.gov/issue/diagnostic-errors-primary-care Case analysis provides important opportunities to highlight factors that culminate in diagnostic error. This website supports learning generated from the Primary-Care…

5354. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36146/psn-pdf
      February 05, 2019 - Guidelines for Design and Construction. February 5, 2019 St Louis, Missouri; Facilities Guidelines Institute; 2018. https://psnet.ahrq.gov/issue/guidelines-design-and-construction These updated guidelines include design changes, such as the adoption of private rooms to reduce medical error, interruptions, and hosp…

5355. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42600/psn-pdf
      September 18, 2013 - Oral medications inadvertently given via the intravenous route. September 18, 2013 Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91. https://psnet.ahrq.gov/issue/oral-medications-inadvertently-given-intravenous-route Analyzing data submitted to the Pennsylvania Patient Safety Reporti…

5356. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38021/psn-pdf
      August 27, 2008 - A review of the current evidence base for significant event analysis. August 27, 2008 Bowie P, Pope L, Lough M. A review of the current evidence base for significant event analysis. J Eval Clin Pract. 2008;14(4):520-36. doi:10.1111/j.1365-2753.2007.00908.x. https://psnet.ahrq.gov/issue/review-current-evidence-base…

5357. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38267/psn-pdf
      December 03, 2008 - National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare. December 3, 2008 National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194. https://psnet.ahrq.gov/issue/national-priorities-and-goals-aligning-our-efforts-transform-americas-healthcare This…

5358. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41592/psn-pdf
      August 15, 2012 - Failure mode and effects analysis outputs: are they valid? August 15, 2012 Shebl NA, Franklin BD, Barber N. Failure mode and effects analysis outputs: are they valid? BMC Health Serv Res. 2012;12:150. doi:10.1186/1472-6963-12-150. https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-outputs-are-they-valid…

5359. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42772/psn-pdf
      January 01, 2014 - Hard Truths: the Journey to Putting Patients First. November 27, 2013 Department of Health. London, England: Crown Publishing; January 2014. ISBN: 9780101877725. https://psnet.ahrq.gov/issue/hard-truths-journey-putting-patients-first This two-part report outlines actions that health care leaders in the United Kingd…

5360. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36845/psn-pdf
      August 29, 2011 - Near miss audit in obstetrics. August 29, 2011 Penney G, Brace V. Near miss audit in obstetrics. Curr Opin Obstet Gynecol. 2007;19(2):145-150. https://psnet.ahrq.gov/issue/near-miss-audit-obstetrics Reviewing studies about maternal morbidity, the authors discuss the various measurement approaches used to identify …