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5661. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50896/psn-pdf
      February 12, 2020 - Medical abbreviations that have contradictory or ambiguous meanings. February 12, 2020 Davis N. ISMP Medication Safety Alert! Acute care edition! January 30, 2020;25(2):1-5. https://psnet.ahrq.gov/issue/medical-abbreviations-have-contradictory-or-ambiguous-meanings Multiple organizations have identified using…

5662. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42712/psn-pdf
      October 02, 2017 - Improving patient safety through transparency. October 2, 2017 Kachalia A. Improving patient safety through transparency. N Engl J Med. 2013;369(18):1677-9. doi:10.1056/NEJMp1303960. https://psnet.ahrq.gov/issue/improving-patient-safety-through-transparency This commentary describes successful transparency initiat…

5663. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39196/psn-pdf
      January 16, 2010 - Detecting adverse events in dermatologic surgery. January 16, 2010 Pinney D, Pearce DJ, Feldman SR. Detecting adverse events in dermatologic surgery. Dermatol Surg. 2010;36(1):8-14. doi:10.1111/j.1524-4725.2009.01378.x. https://psnet.ahrq.gov/issue/detecting-adverse-events-dermatologic-surgery This review identifi…

5664. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37002/psn-pdf
      September 14, 2011 - Factors influencing nurses' decisions to raise concerns about care quality. September 14, 2011 Attree M. Factors influencing nurses' decisions to raise concerns about care quality. J Nurs Manag. 2007;15(4):392-402. https://psnet.ahrq.gov/issue/factors-influencing-nurses-decisions-raise-concerns-about-care-quality …

5665. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41508/psn-pdf
      July 11, 2012 - Complications in surgery: root cause analysis and preventive measures. July 11, 2012 Chung KC, Kotsis S. Complications in surgery: root cause analysis and preventive measures. Plast Reconstr Surg. 2012;129(6):1421-1427. doi:10.1097/PRS.0b013e31824ecda0. https://psnet.ahrq.gov/issue/complications-surgery-root-cause…

5666. 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…

5667. 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…

5668. 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…

5669. 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…

5670. 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…

5671. 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…

5672. 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…

5673. 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…

5674. 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…

5675. 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…

5676. 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-…

5677. 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-…

5678. 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…

5679. 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 …

5680. 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…