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121. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42141/psn-pdf
     April 03, 2013 - The silence of the unblown whistle: the Nevada hepatitis C public health crisis. April 3, 2013 Leary E, Diers D. The silence of the unblown whistle: the Nevada hepatitis C public health crisis. Yale J Biol Med. 2013;86(1):79-87. https://psnet.ahrq.gov/issue/silence-unblown-whistle-nevada-hepatitis-c-public-health-…

122. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45462/psn-pdf
     August 31, 2016 - Learning From Mistakes. August 31, 2016 London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764. https://psnet.ahrq.gov/issue/learning-mistakes The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the…

123. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851067/psn-pdf
     June 28, 2023 - Assessing medication safety in settings not designated solely for pediatric patients. June 28, 2023 ISMP Medication Safety Alert! Acute care edition. June 15, 2023;28(12);1-5. https://psnet.ahrq.gov/issue/assessing-medication-safety-settings-not-designated-solely-pediatric-patients Pediatric patients are at increa…

124. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47369/psn-pdf
     April 08, 2019 - Why do hundreds of US women die annually in childbirth? April 8, 2019 Slomski A. Why Do Hundreds of US Women Die Annually in Childbirth? JAMA. 2019;321(13):1239-1241. doi:10.1001/jama.2019.0714. https://psnet.ahrq.gov/issue/why-do-hundreds-us-women-die-annually-childbirth Maternal mortality is a sentinel event th…

125. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/852449/psn-pdf
     August 16, 2023 - Missed nursing care in emergency departments: a scoping review. August 16, 2023 Duhalde H, Bjuresäter K, Karlsson I, et al. Missed nursing care in emergency departments: a scoping review. Int Emerg Nurs. 2023;69:101296. doi:10.1016/j.ienj.2023.101296. https://psnet.ahrq.gov/issue/missed-nursing-care-emergency-depa…

126. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838125/psn-pdf
     September 22, 2022 - Frontiers in measuring structural racism and its health effects. September 22, 2022 Brown TH, Homan PA. Frontiers in measuring structural racism and its health effects. Health Serv Res. 2022;57(3):443-447. doi:10.1111/1475-6773.13978. https://psnet.ahrq.gov/issue/frontiers-measuring-structural-racism-and-its-healt…

127. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/864846/psn-pdf
     March 20, 2024 - The association between nurse staffing and quality of care in emergency departments: a systematic review. March 20, 2024 Drennan J, Murphy A, McCarthy VJC, et al. The association between nurse staffing and quality of care in emergency departments: a systematic review. Int J Nurs Stud. 2024;153:104706. doi:10.1016/…

128. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44241/psn-pdf
     November 09, 2015 - The overlooked danger of delirium in hospitals. November 9, 2015 Boodman SG. The Atlantic. June 7, 2015. https://psnet.ahrq.gov/issue/overlooked-danger-delirium-hospitals Delirium is a common unintended consequence of hospitalization, most often following a surgical procedure. This magazine article discusses chara…

129. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34668/psn-pdf
     June 06, 2018 - Please don't sleep through this wake-up call. June 6, 2018 ISMP Medication Safety Alert! Acute Care Edition. May 2, 2001.   https://psnet.ahrq.gov/issue/please-dont-sleep-through-wake-call This is an alert from the Institute for Safe Medication Practices informing readers of a fatal medication error that occu…

130. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47453/psn-pdf
     May 20, 2019 - Patient safety and the ageing physician: a qualitative study of key stakeholder attitudes and experiences. May 20, 2019 White AA, Sage WM, Osinska PH, et al. Patient safety and the ageing physician: a qualitative study of key stakeholder attitudes and experiences. BMJ Qual Saf. 2019;28(6):468-475. doi:10.1136/bmjqs…

131. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73345/psn-pdf
     June 02, 2021 - An estimate of missed pediatric sepsis in the emergency department. June 2, 2021 Cifra CL, Westlund E, Ten Eyck P, et al. An estimate of missed pediatric sepsis in the emergency department. Diagnosis (Berl). 2020;8(2):193-198. doi:10.1515/dx-2020-0023. https://psnet.ahrq.gov/issue/estimate-missed-pediatric-sepsis-…

132. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34752/psn-pdf
     November 18, 2015 - Demanding Medical Excellence. Doctors and Accountability in the Information Age. November 18, 2015 Millenson ML. Chicago, IL: University of Chicago Press; 1999. ISBN: 9780226525884. https://psnet.ahrq.gov/issue/demanding-medical-excellence-doctors-and-accountability-information-age Millenson, a Pulitzer-nomin…

133. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/852462/psn-pdf
     August 16, 2023 - American Geriatrics Society 2023 updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. August 16, 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. J Am Geriatr Soc. 2023;71(7):2052- 2081. https://psnet.ahrq.gov/issue/american-geriatrics-society-2023-updated-…

134. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50884/psn-pdf
     February 12, 2020 - Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization. February 12, 2020 Goyal P, Kneifati-Hayek J, Archambault A, et al. Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization. JACC Heart Fail. 2019;8(1):25-34. do…

135. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836978/psn-pdf
     May 16, 2022 - Check Twice, Transport Once May 16, 2022 DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/check-twice-transport-once The Case Case #1: A 26-year-old woman (Patient A) presented to the Emergency Department (ED) with abdominal pain and was diagnosed with “s…

136. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865662/psn-pdf
     April 24, 2024 - Oncologist perceptions of racial disparity, racial anxiety, and unconscious bias in clinical interactions, treatment, and outcomes. April 24, 2024 Balanean A, Bland E, Gajra A, et al. Oncologist perceptions of racial disparity, racial anxiety, and unconscious bias in clinical interactions, treatment, and outcomes.…

137. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866517/psn-pdf
     August 14, 2024 - Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. August 14, 2024 Aikens RC, Chen JH, Baiocchi M, et al. Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. Med Decis Making. 2024;44(5):481-496. doi:10.1177/0272989x241248612. https://p…

138. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37811/psn-pdf
     November 17, 2011 - Acute Hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic—Nevada, 2007. November 17, 2011 Prevention C for DC and. Acute hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic--Nevada, 2007. MMWR Morb Mortal Wkly Rep. 2008;57(19):513-7. …

139. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34697/psn-pdf
     December 08, 2010 - Sentinel events. In memory of Ben—a case study. December 8, 2010 Haas D. Sentinel events. In memory of Ben--a case study. Jt Comm Perspect. 1997;17(2):12-5. https://psnet.ahrq.gov/issue/sentinel-events-memory-ben-case-study Written from the perspective of a risk manager, the author tells the story of a medication a…

140. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45387/psn-pdf
     August 15, 2016 - Preventing medication errors. August 15, 2016 Stefanacci RG, Riddle A. Preventing medication errors. Geriatr Nurs. 2016;37(4):307-10. doi:10.1016/j.gerinurse.2016.06.005. https://psnet.ahrq.gov/issue/preventing-medication-errors Nursing home patients are particularly vulnerable to medication errors. This commentar…