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9501. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39465/psn-pdf
      May 08, 2018 - Latest heparin fatality speaks loudly—what have you done to stop the bleeding? May 8, 2018 ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3. https://psnet.ahrq.gov/issue/latest-heparin-fatality-speaks-loudly-what-have-you-done-stop-bleeding Detailing a recent lethal overdose of heparin, this …

9502. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42523/psn-pdf
      October 08, 2013 - Patient safety in clinical research articles. October 8, 2013 Vintzileos AM, Finamore PS, Sicuranza GB, et al. Patient safety in clinical research articles. Int J Gynaecol Obstet. 2013;123(2):93-5. doi:10.1016/j.ijgo.2013.05.006. https://psnet.ahrq.gov/issue/patient-safety-clinical-research-articles This commentar…

9503. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39288/psn-pdf
      February 10, 2010 - Patient Safety Act. February 10, 2010 Washington, DC: United States Government Accountability Office; January 28, 2010. Publication GAO-10- 281. https://psnet.ahrq.gov/issue/patient-safety-act This report describes progress in implementing the Patient Safety and Quality Improvement Act. The document details devel…

9504. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47472/psn-pdf
      October 24, 2018 - Patient Safety Certificate Course. October 24, 2018 American Board of Quality Assurance and Utilization Review Physicians; ABQAURP. https://psnet.ahrq.gov/issue/patient-safety-certificate-course This online course offers three modules designed to build awareness of key patient safety topics, including how to ident…

9505. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33868/psn-pdf
      October 01, 2018 - Safety in the Retail Pharmacy October 1, 2018 Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/safety-retail-pharmacy Perspective There are approximately 67,000 retail/community pharmacies dispensing 4.4 billion prescriptions each year.(1) Many patients interact w…

9506. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50393/psn-pdf
      September 01, 2019 - Patient Safety and the Evolution of WebM&M and PSNet September 1, 2019 Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet Perspective Progress in any field requires scholarship and dissem…

9507. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33601/psn-pdf
      December 15, 2024 - Electronic Health Records December 15, 2024 Electronic Health Records. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/electronic-health-records PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safet…

9508. Topics | PSNet
      psnet.ahrq.gov/topics-0
      March 03, 2025 - Topics Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts. Featured Topics in Patient Safety Updated Date: March 3, 2025 …

9509. Healthcare-associated Infections | PSNet
      psnet.ahrq.gov/primer/health-care-associated-infections
      December 15, 2024 - Healthcare-associated Infections Citation Text: Healthcare - Associated Infections. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

9510. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35318/psn-pdf
      September 20, 2024 - AHRQ Quality Indicators. September 20, 2024 Agency for Healthcare Research and Quality https://psnet.ahrq.gov/issue/ahrq-quality-indicators The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QIs) represent quality measures that make use of a hospital's available administrative data to inform…

9511. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35441/psn-pdf
      September 18, 2009 - Bridging the communication gap in the operating room with medical team training. September 18, 2009 Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg. 2005;190(5):770-4. https://psnet.ahrq.gov/issue/bridging-communication-gap-operating-r…

9512. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45840/psn-pdf
      February 08, 2017 - Implementation of the safety huddle. February 8, 2017 Kylor C, Napier T, Rephann A, et al. Implementation of the Safety Huddle. Crit Care Nurse. 2016;36(6):80- 82. https://psnet.ahrq.gov/issue/implementation-safety-huddle The safety huddle is becoming common within health care practice as a way to inform clinician…

9513. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841489/psn-pdf
      December 14, 2022 - Rise to Health Coalition. December 14, 2022 Boston, MA; Institute for Healthcare Improvement: December 2022. https://psnet.ahrq.gov/issue/rise-health-coalition Systemic efforts to improve health equity support patient safety. This announcement highlights an initiative for collective work to address four areas of e…

9514. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44583/psn-pdf
      February 17, 2016 - Root Cause Analysis Playbook. February 17, 2016 Chicago, IL: American Society for Healthcare Risk Management; 2015. https://psnet.ahrq.gov/issue/root-cause-analysis-playbook Risk management has recently focused on organization-wide improvement in patient safety. This publication discusses root cause analysis metho…

9515. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39982/psn-pdf
      January 17, 2012 - Hand-off Communications. January 17, 2012 DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. https://psnet.ahrq.gov/issue/hand-communications The Joint Commission Center for Transforming Hea…

9516. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/856639/psn-pdf
      November 29, 2023 - Impact Wellbeing. November 29, 2023 National Institute for Occupational Safety and Health. Centers for Disease Control and Prevention. https://psnet.ahrq.gov/issue/impact-wellbeing Clinician burnout has become a major concern for both healthcare workforce and patient safety. This portal provides access to too…

9517. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45287/psn-pdf
      August 03, 2016 - Mistakes We Make in Dialysis. August 3, 2016 Rodby RA, Perazella MA, eds. Semin Dial. 2016;29(4):253-328. https://psnet.ahrq.gov/issue/mistakes-we-make-dialysis Insufficient application of new evidence to inform treatment decisions can hinder safe care delivery. Articles in this special issue explore common renal …

9518. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42131/psn-pdf
      March 20, 2013 - What surgeons leave behind costs some patients dearly. March 20, 2013 Eisler P. https://psnet.ahrq.gov/issue/what-surgeons-leave-behind-costs-some-patients-dearly This newspaper article describes two incidents of retained surgical items and discusses the technological solutions to prevent them. https://psnet.ahrq…

9519. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841198/psn-pdf
      December 07, 2022 - Technology, Education and Safety. December 7, 2022 Arna D, ed. Curr Opin Anaesthesiol. 2022;35(6):710-737. https://psnet.ahrq.gov/issue/technology-education-and-safety-1 Safety challenges in anesthesiology and perioperative care are high-risk situations. This segment of a reoccurring special section covers strateg…

9520. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43454/psn-pdf
      November 20, 2015 - Training in quality and safety: the current landscape. November 20, 2015 Karasick AS, Nash DB. Training in quality and safety: the current landscape. Am J Med Qual. 2015;30(6):526-38. doi:10.1177/1062860614544194. https://psnet.ahrq.gov/issue/training-quality-and-safety-current-landscape This commentary offers inf…