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21. Ten years later, alarm fatigue is still a safety concern. | PSNet
    psnet.ahrq.gov/issue/ten-years-later-alarm-fatigue-still-safety-concern
    October 25, 2023 - Clinical approaches include customization of alert parameters to reduce nonactionable alarms, while … engineering solutions include reducing the volume or adjusting the tone of auditory alerts.

22. MHA and MHA Keystone Center Annual Reports. | PSNet
    psnet.ahrq.gov/issue/transformation-through-collaboration-2018-2019-mha-keystone-center-annual-report
    September 26, 2016 - The achievements noted in the 2022-2023 data review include reduction both fall and blood- or blood-product … Areas of focus for improvement work reported on include health equity , workforce wellbeing, and maternal

23. Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM) Shows Promise for Targeting Prevention Interventions to Reduce Mortality in Patients Who Are Prescribed Opioids | PSNet
    psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-mitigation-storm-shows
    October 30, 2024 - Note that the target population does not include patients with OUD in medication-assisted treatment ( … STORM is one of several VHA overdose prevention initiatives that include the distribution of naloxone … Teams must include a facility lead and representation from the facility’s substance abuse disorder (SUD … Key features include the following: Data that populates a clinical decision support tool that is … Case reviews are conducted by an interdisciplinary team and include follow-up to ensure a treatment plan

24. Ten principles for more conservative, care-full diagnosis. | PSNet
    psnet.ahrq.gov/issue/ten-principles-more-conservative-care-full-diagnosis
    August 04, 2021 - Recommendation highlights include a renewed focus on history-taking and physician examination, as discussed … May 1, 2019 How often do prescribers include indications in drug orders?

25. Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis. | PSNet
    psnet.ahrq.gov/issue/indication-documentation-and-indication-based-prescribing-within-electronic-prescribing
    December 18, 2019 - Requiring a prescriber to include an indication for a medication can reduce the risk of wrong-patient … This review identified 21 studies describing interventions to encourage prescribers to include indications

26. FDA Safety Communication: update--robotically-assisted surgical devices in mastectomy. | PSNet
    psnet.ahrq.gov/issue/fda-safety-communication-caution-when-using-robotically-assisted-surgical-devices-womens
    September 01, 2021 - Recommendations for patients who may seek to have robotically assisted surgery include asking about their … Suggestions for health care providers include completing specialized training on procedures they perform

27. Barriers to and facilitators of bedside nursing handover: a systematic review and meta-synthesis. | PSNet
    psnet.ahrq.gov/issue/barriers-and-facilitators-bedside-nursing-handover-systematic-review-and-meta-synthesis
    August 25, 2021 - Benefits include humanization of the patient and improved patient safety; barriers include provider

28. Listening to women: recommendations from women of color to improve experiences in pregnancy and birth care. | PSNet
    psnet.ahrq.gov/issue/listening-women-recommendations-women-color-improve-experiences-pregnancy-and-birth-care
    August 12, 2019 - Recommendations for providers include the inclusion of patients as partners in decision making and … Recommendations for health care systems include implicit bias training and education to reduce judgment

29. Patient and caregiver perspectives on causes and prevention of ambulatory adverse events: multilingual qualitative study. | PSNet
    psnet.ahrq.gov/issue/patient-and-caregiver-perspectives-causes-and-prevention-ambulatory-adverse-events
    November 24, 2021 - Adverse event (AE) investigations typically only include organizational or regulatory professionals … Themes identified include: (1) patients and teams have specific safety responsibilities; (2) proactive

30. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/39946/psn-pdf
    October 20, 2023 - The achievements noted in the 2022-2023 data review include reduction both fall and blood- or blood-product … Areas of focus for improvement work reported on include health equity, workforce wellbeing, and maternal

31. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45607/psn-pdf
    July 14, 2019 - The materials include information on collaborative projects led by the Duke Patient Safety Center and … Current areas of emphasis include building resilience and joy in practice.

32. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/47803/psn-pdf
    October 07, 2021 - User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties … Recommendations include ensuring availability of various staple sizes and avoiding use of staples on

33. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/50921/psn-pdf
    February 19, 2020 - factors in retail pharmacy environment that degrade pharmacists’ ability to safely practice, which include … Strategies highlighted to mitigate the problem that have been inconsistently applied include scheduled

34. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/839326/psn-pdf
    November 02, 2022 - This article discusses factors that contribute to medication errors and smart pumps, which include out-of-date … Recommendations for improvement include the creation, testing, and updating of drug libraries.

35. Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications. | PSNet
    psnet.ahrq.gov/issue/use-strategies-high-reliability-organisations-patient-hand-resident-physicians-practical
    July 02, 2014 - The integral components of an effective signout include providing accurate and updated information, … Unfortunately, this mixed-methods study found that most resident handoffs did not include these key elements

36. Racial and ethnic disparities in patient safety. | PSNet
    psnet.ahrq.gov/issue/racial-and-ethnic-disparities-patient-safety
    March 03, 2011 - The authors found that safety research does not uniformly include ethnically diverse populations or adjust … improve characterization of the role disparities play in adverse events, the authors call for research to include

37. Does full disclosure of medical errors affect malpractice liability? The jury is still out. | PSNet
    psnet.ahrq.gov/issue/does-full-disclosure-medical-errors-affect-malpractice-liability-jury-still-out
    November 16, 2011 - Notable factors suggested from the literature include poor communication with patients, the presence … May 20, 2015 Disclosure-and-resolution programs that include generous compensation offers

38. Good Practice Guides on Medication Errors: Part 1 and Part 2. | PSNet
    psnet.ahrq.gov/issue/good-practice-guides-medication-errors-part-1-and-part-2
    August 03, 2016 - Recommendations include expanding the definition of adverse reaction to include medication errors

39. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/848088/psn-pdf
    April 26, 2023 - Safety recommendations include changes in medical education on how to handle uncertainty in clinical … settings and amending dialysis guidelines to include risk of air embolus associated with unclamped

40. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/853610/psn-pdf
    September 20, 2023 - Clinical approaches include customization of alert parameters to reduce nonactionable alarms, while … engineering solutions include reducing the volume or adjusting the tone of auditory alerts.