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6681. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41900/psn-pdf
      December 05, 2012 - Impact of an intervention to reduce prescribing errors in a pediatric intensive care unit. December 5, 2012 Martinez-Anton A, Sanchez I, Casanueva L. Impact of an intervention to reduce prescribing errors in a pediatric intensive care unit. Intensive Care Med. 2012;38(9):1532-8. doi:10.1007/s00134-012-2609-x. http…

6682. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47788/psn-pdf
      March 06, 2019 - Medical device-related pressure ulcers: a systematic review and meta-analysis. March 6, 2019 Jackson D, Sarki AM, Betteridge R, et al. Medical device-related pressure ulcers: A systematic review and meta-analysis. Int J Nurs Stud. 2019;92:109-120. doi:10.1016/j.ijnurstu.2019.02.006. https://psnet.ahrq.gov/issue/me…

6683. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43069/psn-pdf
      April 16, 2014 - Decimal numbers and safe interpretation of clinical pathology results. April 16, 2014 Sinnott M, Eley R, Steinle V, et al. Decimal numbers and safe interpretation of clinical pathology results. J Clin Pathol. 2014;67(2):179-81. doi:10.1136/jclinpath-2013-201865. https://psnet.ahrq.gov/issue/decimal-numbers-and-saf…

6684. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39090/psn-pdf
      November 11, 2009 - Nurse reports of adverse events during sedation procedures at a pediatric hospital. November 11, 2009 Lightdale JR, Mahoney LB, Fredette ME, et al. Nurse reports of adverse events during sedation procedures at a pediatric hospital. J Perianesth Nurs. 2009;24(5):300-6. doi:10.1016/j.jopan.2009.07.004. https://psnet…

6685. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72583/psn-pdf
      December 16, 2020 - Wear face masks with no metal during MRI exams. December 16, 2020 FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 7, 2020. https://psnet.ahrq.gov/issue/wear-face-masks-no-metal-during-mri-exams Magnetic resonance imaging (MRI) requires patient prep…

6686. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36615/psn-pdf
      January 14, 2011 - The Patient Safety and Quality Improvement Act of 2005: provisions and potential opportunities. January 14, 2011 Liang BA, Riley W, Rutherford W, et al. The Patient Safety and Quality Improvement Act of 2005: Provisions and Potential Opportunities. American Journal of Medical Quality. 2007;22(1). doi:10.1177/10628…

6687. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43394/psn-pdf
      July 30, 2014 - With oral chemotherapy, we simply must do better! July 30, 2014 ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4. https://psnet.ahrq.gov/issue/oral-chemotherapy-we-simply-must-do-better To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter …

6688. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863003/psn-pdf
      February 21, 2024 - Positive Patient Identification. February 21, 2024 Healthcare Safety Investigation Branch (HSIB), Dorset, UK:  Health Services Safety Investigations Body; February 2024. https://psnet.ahrq.gov/issue/positive-patient-identification Patient misidentification can result in medication administration errors, …

6689. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41051/psn-pdf
      February 20, 2012 - What do patients and relatives know about problems and failures in care? February 20, 2012 Iedema R, Allen S, Britton K, et al. What do patients and relatives know about problems and failures in care? BMJ Qual Saf. 2012;21(3):198-205. doi:10.1136/bmjqs-2011-000100. https://psnet.ahrq.gov/issue/what-do-patients-and…

6690. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47781/psn-pdf
      February 27, 2019 - Medicine Safety: Take Care. February 27, 2019 Lim R, Semple S, Ellett LK, Roughead L. Canberra, Australia: Pharmaceutical Society of Australia; 2019. https://psnet.ahrq.gov/issue/medicine-safety-take-care Analyzing the evidence on medication errors in Australia, this report estimates the incidence of acute care ad…

6691. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/845351/psn-pdf
      March 01, 2023 - Access to Clinical Information at the Bedside. March 1, 2023 Farnborough, UK: Healthcare Safety Investigation Branch; February 2023. https://psnet.ahrq.gov/issue/access-clinical-information-bedside Patient misidentification in emergent situations can reduce the appropriateness of care delivery and safety. This rep…

6692. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40323/psn-pdf
      December 29, 2014 - Hospitalized patients' participation and its impact on quality of care and patient safety. December 29, 2014 Weingart SN, Zhu J, Chiappetta L, et al. Hospitalized patients' participation and its impact on quality of care and patient safety. Int J Qual Health Care. 2011;23(3):269-77. doi:10.1093/intqhc/mzr002. http…

6693. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866530/psn-pdf
      August 14, 2024 - Healthcare Simulation in Nursing Practice. August 14, 2024 Watts PI. Healthcare Simulation in Nursing Practice. Nurs Clin North Am. 2024;59(3):345-510. https://psnet.ahrq.gov/issue/healthcare-simulation-nursing-practice Simulation is an established method to examine nursing process resilience and develop non-techni…

6694. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47955/psn-pdf
      April 17, 2019 - Will human factors restore faith in the GMC? April 17, 2019 Morgan L, Benson D, McCulloch P. Will human factors restore faith in the GMC? BMJ. 2019;364:l1037. doi:10.1136/bmj.l1037. https://psnet.ahrq.gov/issue/will-human-factors-restore-faith-gmc Investigations into medical mistakes that result in patient harm sh…

6695. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46520/psn-pdf
      December 19, 2017 - The emotional fallout from the culture of blame and shame. December 19, 2017 Ferguson CC. The emotional fallout from the culture of blame and shame. JAMA Pediatr. 2017;171(12):1141. doi:10.1001/jamapediatrics.2017.2691. https://psnet.ahrq.gov/issue/emotional-fallout-culture-blame-and-shame In this commentary, a p…

6696. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36367/psn-pdf
      April 11, 2011 - Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital setting. April 11, 2011 Kaji AH, Gausche-Hill M, Conrad H, et al. Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital setting. Pediatrics. 2006;118(4):1493-150…

6697. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838909/psn-pdf
      October 26, 2022 - Designing safety interventions for specific contexts: results from a literature review. October 26, 2022 Karanikas N, Khan SR, Baker PRA, et al. Designing safety interventions for specific contexts: Results from a literature review. Safety Sci. 2022;156:105906. doi:10.1016/j.ssci.2022.105906. https://psnet.ahrq.go…

6698. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44879/psn-pdf
      February 10, 2016 - Soaring numbers of 111 callers forced to wait for a call back. February 10, 2016 Donnelly L. The Telegraph. January 31, 2016. https://psnet.ahrq.gov/issue/soaring-numbers-111-callers-forced-wait-call-back Delays in care and diagnosis can result in patient harm. This news article reports on the trend of delays in …

6699. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34708/psn-pdf
      February 18, 2011 - Understanding and responding to adverse events. February 18, 2011 Vincent CA. Understanding and Responding to Adverse Events. New Engl J Med. 2003;348(11):1051- 1056. doi:10.1056/nejmhpr020760. https://psnet.ahrq.gov/issue/understanding-and-responding-adverse-events In this article, Vincent describes the investiga…

6700. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60889/psn-pdf
      January 01, 2021 - Expert consensus on currently accepted measures of harm. September 9, 2020 Logan MS, Myers LC, Salmasian H, et al. Expert consensus on currently accepted measures of harm. J Patient Saf. 2021;17(8):e1726-e1731. doi:10.1097/pts.0000000000000754. https://psnet.ahrq.gov/issue/expert-consensus-currently-accepted-measu…