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psnet.ahrq.gov/periodic-issue/periodic-issue-470December 31, 2024 - January 15, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, report…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836790/psn-pdfMarch 23, 2022 - Human Factors In Healthcare. March 23, 2022 Keebler JR, Salas E, Rosen MA, et al. eds. Hum Factors. 2022;64(1):5-258. https://psnet.ahrq.gov/issue/human-factors-healthcare Human factors concepts are central to improvement in high-risk industries and efforts are emerging to enfold them into health care organization… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46727/psn-pdfAugust 21, 2021 - Alliance for Innovation on Maternal Health. August 21, 2021 American College of Obstetricians and Gynecologists. https://psnet.ahrq.gov/issue/alliance-innovation-maternal-health This website provides information from a multidisciplinary collaboration whose mission was to support safe health care for pregnant and p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42166/psn-pdfJune 10, 2018 - Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. March 21, 2013;18:1-3. https://psnet.ahrq.gov/issue/drawn-curtains-muted-alarms-and-diverted-attention-lead-tragedy- postanesthesia-care-unit This n… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60634/psn-pdfJanuary 01, 2021 - Quality & safety in the time of coronavirus--design better, learn faster. July 1, 2020 Fitzsimons J. Quality and safety in the time of Coronavirus: design better, learn faster. Int J Qual Health Care. 2021;33(1):mzaa051. doi:10.1093/intqhc/mzaa051. https://psnet.ahrq.gov/issue/quality-safety-time-coronavirus-desig… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45324/psn-pdfAugust 31, 2016 - The problem with medication reconciliation. August 31, 2016 Pevnick JM, Shane R, Schnipper JL. The problem with medication reconciliation. BMJ Qual Saf. 2016;25(9):726-730. doi:10.1136/bmjqs-2015-004734. https://psnet.ahrq.gov/issue/problem-medication-reconciliation Medication reconciliation has demonstrated safet… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/838320/psn-pdfMay 12, 2010 - Regional variations in diagnostic practices. May 12, 2010 Song Y, Skinner J, Bynum JPW, et al. Regional variations in diagnostic practices. N Engl J Med. 2010;363(1):45-53. doi:10.1056/nejmsa0910881. https://psnet.ahrq.gov/issue/regional-variations-diagnostic-practices Improving diagnostic safety is a national pri… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39086/psn-pdfMay 24, 2015 - Psychiatry morbidity and mortality rounds: implementation and impact. May 24, 2015 Goldman S, Demaso DR, Kemler B. Psychiatry morbidity and mortality rounds: implementation and impact. Acad Psychiatry. 2009;33(5):383-8. doi:10.1176/appi.ap.33.5.383. https://psnet.ahrq.gov/issue/psychiatry-morbidity-and-mortality-r… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43974/psn-pdfApril 26, 2015 - 2014 John M. Eisenberg Patient Safety and Quality Award Recipients Announced. April 26, 2015 Joint Commission. https://psnet.ahrq.gov/issue/2014-john-m-eisenberg-patient-safety-and-quality-award-recipients-announced The Eisenberg Award honors individuals and organizations who have made vital accomplishments in im… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36658/psn-pdfMay 27, 2011 - Potassium and phosphorus repletion in hospitalized patients: implications for clinical practice and the potential use of healthcare information technology to improve prescribing and patient safety. May 27, 2011 Hemstreet BA, Stolpman N, Badesch DB, et al. Potassium and phosphorus repletion in hospitalized patient… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/838191/psn-pdfSeptember 28, 2022 - Improved Diagnostic Accuracy Through Probability- Based Diagnosis. September 28, 2022 Rockville, MD: Agency for Healthcare Research and Quality; September 2022. AHRQ Publication No. 22- 0026-3-EF. https://psnet.ahrq.gov/issue/improved-diagnostic-accuracy-through-probability-based-diagnosis Correct consideration o… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40944/psn-pdfMarch 06, 2012 - Using the Agency for Healthcare Research and Quality Patient Safety Indicators for targeting nursing quality improvement. March 6, 2012 Zrelak PA, Utter GH, Sadeghi B, et al. Using the Agency for Healthcare Research and Quality patient safety indicators for targeting nursing quality improvement. J Nurs Care Qual. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47827/psn-pdfFebruary 27, 2019 - Improving Usability, Safety and Patient Outcomes With Health Information Technology. February 27, 2019 Lau F, Bartle-Clar JA, Bliss G, et al, eds. Stud Health Technol Inform. 2019;257:1-539. ISBN: 9781614999508. https://psnet.ahrq.gov/issue/improving-usability-safety-and-patient-outcomes-health-information-technol… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/839814/psn-pdfJanuary 01, 2023 - Influencing a culture of quality and safety through huddles. November 9, 2022 McCain N, Ferguson T, Barry Hultquist T, et al. Influencing a culture of quality and safety through huddles. J Nurs Care Qual. 2023;38(1):26-32. doi:10.1097/ncq.0000000000000642. https://psnet.ahrq.gov/issue/influencing-culture-quality-a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/838083/psn-pdfSeptember 14, 2022 - A pause in pediatrics: implementation of a pediatric diagnostic time-out. September 14, 2022 Yale SC, Cohen SS, Kliegman RM, et al. A pause in pediatrics: implementation of a pediatric diagnostic time-out. Diagnosis (Berl). 2022;9(3):348-351. doi:10.1515/dx-2022-0010. https://psnet.ahrq.gov/issue/pause-pediatrics-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46586/psn-pdfJanuary 01, 2020 - Adverse event reporting: harnessing residents to improve patient safety. November 8, 2017 Tevis SE, Schmocker RK, Wetterneck TB. Adverse Event Reporting. J Patient Saf. 2020;16(4):294-298. doi:10.1097/pts.0000000000000333. https://psnet.ahrq.gov/issue/adverse-event-reporting-harnessing-residents-improve-patient-sa… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36520/psn-pdfJune 14, 2011 - Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. June 14, 2011 Braithwaite J, Westbrook MT, Mallock NA, et al. Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Qual Saf Health… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42456/psn-pdfSeptember 09, 2013 - A toolkit to disseminate best practices in inpatient medication reconciliation: Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). September 9, 2013 Mueller SK, Kripalani S, Stein J, et al. A toolkit to disseminate best practices in inpatient medication reconciliation: multi-center medicat… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/74048/psn-pdfNovember 10, 2021 - Causes of use errors in ventilation devices--systematic review. November 10, 2021 Coldewey B, Diruf A, Röhrig R, et al. Causes of use errors in ventilation devices - systematic review. Appl Ergon. 2021;98:103544. doi:10.1016/j.apergo.2021.103544. https://psnet.ahrq.gov/issue/causes-use-errors-ventilation-devices-s… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42965/psn-pdfApril 20, 2014 - Development of a Web-based surgical booking and informed consent system to reduce the potential for error and improve communication. April 20, 2014 Siracuse JJ, Benoit E, Burke J, et al. Development of a Web-based surgical booking and informed consent system to reduce the potential for error and improve communicat…
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