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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39801/psn-pdfDecember 21, 2014 - Gossypiboma: tales of lost sponges and lessons learned. December 21, 2014 McIntyre LK. Gossypiboma. Archives of Surgery. 2010;145(8). doi:10.1001/archsurg.2010.152. https://psnet.ahrq.gov/issue/gossypiboma-tales-lost-sponges-and-lessons-learned This study describes successful efforts to reduce retained surgical spo… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35306/psn-pdfJuly 14, 2009 - The iatrogenic-harm cost equation and new technology. July 14, 2009 Webster CS. The iatrogenic-harm cost equation and new technology. Anaesthesia. 2005;60(9). doi:10.1111/j.1365-2044.2005.04331.x. https://psnet.ahrq.gov/issue/iatrogenic-harm-cost-equation-and-new-technology The author suggests that greater focus o… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35948/psn-pdfAugust 02, 2010 - Perioperative patient safety: a multisite qualitative analysis. August 2, 2010 Chappy S. Perioperative patient safety: a multisite qualitative analysis. AORN J. 2006;83(4):871-4, 877-88, 891-7. https://psnet.ahrq.gov/issue/perioperative-patient-safety-multisite-qualitative-analysis The author identified the most … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41604/psn-pdfAugust 15, 2012 - Patient data outage exposes risks of electronic medical records. August 15, 2012 Terhune C. https://psnet.ahrq.gov/issue/patient-data-outage-exposes-risks-electronic-medical-records This newspaper article reports on an incident during which dozens of hospitals lost access to electronic medical records (EMRs) and … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36236/psn-pdfApril 12, 2011 - Risk management, or just a different risk? April 12, 2011 Freer Y, Lyon A. Risk management, or just a different risk? Arch Dis Child Fetal Neonatal Ed. 2006;91(5):F327-9. https://psnet.ahrq.gov/issue/risk-management-or-just-different-risk The authors found that clinicians were not likely to alter their practice in… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35729/psn-pdfMay 08, 2018 - Pump up the volume—tips for increasing error reporting. May 8, 2018 ISMP Medication Safety Alert! Acute Care Edition. February 9, 2006;11:1-2,4. https://psnet.ahrq.gov/issue/pump-volume-tips-increasing-error-reporting This article presents best practices in six areas that can influence the success of incident repor… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41197/psn-pdfMarch 07, 2012 - Fear of punitive response to hospital errors lingers. March 7, 2012 O'Reilly KB. American Medical News. February 20, 2012. https://psnet.ahrq.gov/issue/fear-punitive-response-hospital-errors-lingers This news article highlights the problem of blame culture in health care, which hinders incident reporting and safet… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36748/psn-pdfSeptember 27, 2017 - Medication safety in a psychiatric hospital. September 27, 2017 Rothschild JM, Mann K, Keohane C, et al. Medication safety in a psychiatric hospital. Gen Hosp Psychiatry. 2007;29(2):156-62. https://psnet.ahrq.gov/issue/medication-safety-psychiatric-hospital The authors analyzed the incidence and type of medication… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37691/psn-pdfApril 16, 2008 - Medication errors in a neonatal intensive care unit. April 16, 2008 Lerner RB de ME, de Carvalho M, Vieira AA, et al. Medication errors in a neonatal intensive care unit. J Pediatr (Rio J). 2008;84(2):166-70. doi:10.2223/JPED.1757. https://psnet.ahrq.gov/issue/medication-errors-neonatal-intensive-care-unit A high … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37237/psn-pdfDecember 15, 2011 - Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. December 15, 2011 Dekker SWA. Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. J Law Med Ethics. 2007;35(3):463-70. https://psnet.ahrq.gov/issue/discontinuity-and-disaster-gaps-and… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40354/psn-pdfMay 25, 2011 - The influence of resident involvement on surgical outcomes. May 25, 2011 Raval M, Wang X, Cohen ME, et al. The influence of resident involvement on surgical outcomes. J Am Coll Surg. 2011;212(5):889-98. doi:10.1016/j.jamcollsurg.2010.12.029. https://psnet.ahrq.gov/issue/influence-resident-involvement-surgical-outc… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40761/psn-pdfSeptember 12, 2016 - Failure to rescue in neonatal care. September 12, 2016 Gephart SM, McGrath JM, Effken JA. Failure to rescue in neonatal care. J Perinat Neonatal Nurs. 2011;25(3):275-282. doi:10.1097/JPN.0b013e318227cc03. https://psnet.ahrq.gov/issue/failure-rescue-neonatal-care This commentary suggests numerous strategies to redu… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33624/psn-pdfDecember 01, 2005 - employers were smart, they would search for a different approach that accurately identifies when these incidents -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49474/psn-pdfMarch 01, 2005 - Incidents, events and complications in the perioperative period in normal and malnurished patients-- -
psnet.ahrq.gov/web-mm/hidden-mysteryDecember 01, 2011 - Incidents, events and complications in the perioperative period in normal and malnurished patients--results
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40991/psn-pdfJanuary 17, 2017 - MRI safety 10 years later. January 17, 2017 Gilk T, Latino RJ. Patient Saf Qual Healthc. November/December 2011;8:22-23,26-29. https://psnet.ahrq.gov/issue/mri-safety-10-years-later Describing a case of accidental patient death in an MRI suite, this article reviews a root cause analysis of the event and notes that… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35778/psn-pdfJuly 20, 2010 - Accidental iatrogenic pneumothorax in hospitalized patients. July 20, 2010 Zhan C, Smith M, Stryer D. Accidental iatrogenic pneumothorax in hospitalized patients. Med Care. 2006;44(2):182-186. https://psnet.ahrq.gov/issue/accidental-iatrogenic-pneumothorax-hospitalized-patients This Agency for Healthcare Research… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/34002/psn-pdfMarch 17, 2011 - Utah DoH Patient Safety Initiatives. March 17, 2011 Center for Health Data, Utah Department of Health, PO Box 144004, Salt Lake City, UT 84114. https://psnet.ahrq.gov/issue/utah-doh-patient-safety-initiatives Utah established a number of collaborative initiatives to understand the nature and occurrence of adverse … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40553/psn-pdfJune 22, 2011 - Applying the Universal Protocol to improve patient safety in radiology services. June 22, 2011 PA-PSRS Patient Saf Advis. June 2011;8:63-69. https://psnet.ahrq.gov/issue/applying-universal-protocol-improve-patient-safety-radiology-services Exploring causes of wrong-site, wrong patient, and wrong procedure errors i… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40937/psn-pdfNovember 16, 2011 - AHRQ Projects to Prevent Healthcare-Associated Infections, Fiscal Year 2011. November 16, 2011 Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 09- P013-4-E. https://psnet.ahrq.gov/issue/ahrq-projects-prevent-healthcare-associated-infections-fiscal-year-2011 This annou…
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