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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866255/psn-pdf
    July 10, 2024 - Cyberattack led to harrowing lapses at Ascension hospitals, clinicians say. July 10, 2024 Pradhan R, Wells K. KFF Health News and Morning Edition, Michigan Public Radio: June 19, 2024. https://psnet.ahrq.gov/issue/cyberattack-led-harrowing-lapses-ascension-hospitals-clinicians-say Cybersecurity is increasingly see…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37805/psn-pdf
    February 15, 2011 - Designing and implementing a comprehensive quality and patient safety management model: a paradigm for perioperative improvement. February 15, 2011 Herzer KR, Mark LJ, Michelson JD, et al. Designing and Implementing a Comprehensive Quality and Patient Safety Management Model. J Patient Saf. 2008;4(2). doi:10.1097/…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45826/psn-pdf
    January 18, 2017 - Ensuring staff safety when treating potentially violent patients. January 18, 2017 Roca RP, Charen B, Boronow J. Ensuring Staff Safety When Treating Potentially Violent Patients. JAMA. 2016;316(24):2669-2670. doi:10.1001/jama.2016.18260. https://psnet.ahrq.gov/issue/ensuring-staff-safety-when-treating-potentially-…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42100/psn-pdf
    March 13, 2013 - Matching identifiers in electronic health records: implications for duplicate records and patient safety. March 13, 2013 McCoy AB, Wright A, Kahn MG, et al. Matching identifiers in electronic health records: implications for duplicate records and patient safety. BMJ Qual Saf. 2013;22(3):219-24. doi:10.1136/bmjqs-20…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35182/psn-pdf
    April 11, 2011 - Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients. April 11, 2011 Larsen G, Parker HB, Cash J, et al. Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients. Pediatrics. 2005;1…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43750/psn-pdf
    June 21, 2015 - Using a quantitative risk register to promote learning from a patient safety reporting system. June 21, 2015 Mansfield JG, Caplan RA, Campos JS, et al. Using a quantitative risk register to promote learning from a patient safety reporting system. Jt Comm J Qual Patient Saf. 2015;41(2):76-86. https://psnet.ahrq.gov…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43639/psn-pdf
    October 29, 2014 - Ebola case raises concern about everyday hospital safety. October 29, 2014 Rodricks D. Baltimore Sun. October 14, 2014. https://psnet.ahrq.gov/issue/ebola-case-raises-concern-about-everyday-hospital-safety Although significant progress has been made in improving patient safety over the past decade, many medical e…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74042/psn-pdf
    November 03, 2021 - An Investigation into the Death of Baby J at University Hospitals Bristol and Weston NHS Foundation Trust. November 3, 2021 Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021. https://psnet.ahrq.gov/issue/investigation-death-baby-j-university-hospitals-bristol-and-weston-nhs- foundation-trust…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43947/psn-pdf
    August 28, 2015 - AHRQ Health Services Research Projects: Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R01). August 28, 2015 US Department of Health and Human Services. August 25, 2015. PA-15-339. https://psnet.ahrq.gov/issue/ahrq-health-services-research-projects-making-health-care-safer-ambu…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72582/psn-pdf
    December 16, 2020 - Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died. December 16, 2020 Washington, DC: Department of Veterans Affairs, Office of Inspector General; November 17, 2020. Report No 19-08542-11. https://psnet.ahrq.gov/issue/deficiencies-veterans-crisis-line-response-veteran-caller-who-died I…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837214/psn-pdf
    May 25, 2022 - Global Report on Infection Prevention and Control: Executive Summary. May 25, 2022 Geneva, Switzerland; World Health Organization; May 5, 2022. https://psnet.ahrq.gov/issue/global-report-infection-prevention-and-control-executive-summary Healthcare-acquired infection is a persistent systemic problem. This report r…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851194/psn-pdf
    July 05, 2023 - The additional cost of perioperative medication errors July 5, 2023 Langlieb ME, Sharma P, Hocevar M, et al. The additional cost of perioperative medication errors. J Patient Saf. 2023;19(6):375-378. doi:10.1097/pts.0000000000001136. https://psnet.ahrq.gov/issue/additional-cost-perioperative-medication-errors Prev…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50808/psn-pdf
    January 15, 2020 - Health Services Research Priorities for Improving Diagnostic Safety and Quality. Special Emphasis Notice (SEN). January 15, 2020 Rockville, MD: Agency for Healthcare Research and Quality. December 27, 2019. Publication No. NOT- HS-20-004. https://psnet.ahrq.gov/issue/health-services-research-priorities-improving-…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45948/psn-pdf
    January 01, 2021 - Preoperative site marking: are we adhering to good surgical practice? July 26, 2017 Bathla S, Chadwick M, Nevins EJ, et al. Preoperative Site Marking. J Patient Saf. 2021;17(6):e503-e508. doi:10.1097/pts.0000000000000398. https://psnet.ahrq.gov/issue/preoperative-site-marking-are-we-adhering-good-surgical-practice…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38720/psn-pdf
    June 24, 2009 - Patient safety in North America: beyond "operate through your initials" and "sign your site." June 24, 2009 Wong DA, Lewis B, Herndon JH, et al. Patient Safety in North America: Beyond “Operate Through Your Initials” and “Sign Your Site”*. doi:10.2106/jbjs.h.01462. https://psnet.ahrq.gov/issue/patient-safety-north…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44554/psn-pdf
    November 20, 2015 - Hospice diagnosis: polypharmacy—a teachable moment. November 20, 2015 Larson CK, Kao H. Hospice Diagnosis: Polypharmacy: A Teachable Moment. JAMA Intern Med. 2015;175(11):1750-1751. doi:10.1001/jamainternmed.2015.5253. https://psnet.ahrq.gov/issue/hospice-diagnosis-polypharmacy-teachable-moment Overprescribing can…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45373/psn-pdf
    November 18, 2016 - Prevalence, risk factors, and outcomes of idle intravenous catheters: an integrative review. November 18, 2016 Becerra MB, Shirley D, Safdar N. Prevalence, risk factors, and outcomes of idle intravenous catheters: An integrative review. Am J Infect Control. 2016;44(10):e167-e172. doi:10.1016/j.ajic.2016.03.073. ht…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73100/psn-pdf
    March 31, 2021 - Public comment period extended for strategies to improve patient safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine. March 31, 2021 Fed Register. 2021;86(51):14752-14753. https://psnet.ahrq.gov/issue/public-comment-period-extended-strategies-improve-patient-safety-d…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34990/psn-pdf
    June 22, 2009 - Detecting adverse drug reactions on paediatric wards: intensified surveillance versus computerised screening of laboratory values. June 22, 2009 Haffner S, von Laue N, Wirth S, et al. Detecting adverse drug reactions on paediatric wards: intensified surveillance versus computerised screening of laboratory values. …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849613/psn-pdf
    May 31, 2023 - Smart infusion pump investigations after an unexplained over-infusion. May 31, 2023 ISMP Patient Safety Alert! Acute care edition. May 18, 2023;28(10);1-3. https://psnet.ahrq.gov/issue/smart-infusion-pump-investigations-after-unexplained-over-infusion Dose error-reduction systems (DERS) and drug libraries are tool…
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