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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42608/psn-pdfJanuary 09, 2014 - Antiretroviral medication prescribing errors are common with hospitalization of HIV-infected patients. January 9, 2014 Commers T, Swindells S, Sayles H, et al. Antiretroviral medication prescribing errors are common with hospitalization of HIV-infected patients. J Antimicrob Chemother. 2014;69(1):262-7. doi:10.1093… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60669/psn-pdfJuly 08, 2020 - Participation in a system-thinking simulation experience changes adverse event reporting. July 8, 2020 Sanko JS, Mckay M. Participation in a system-thinking simulation experience changes adverse event reporting. Simul Healthc. 2020;15(3):167-171. doi:10.1097/sih.0000000000000473. https://psnet.ahrq.gov/issue/parti… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45469/psn-pdfJanuary 18, 2017 - Tamper-resistant drugs cannot solve the opioid crisis. January 18, 2017 Leece P, Orkin AM, Kahan M. Tamper-resistant drugs cannot solve the opioid crisis. CMAJ. 2015;187(10):717-718. doi:10.1503/cmaj.150329. https://psnet.ahrq.gov/issue/tamper-resistant-drugs-cannot-solve-opioid-crisis Health care organizations ha… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866406/psn-pdfJuly 31, 2024 - Impact of a daily huddle on safety in perioperative services. July 31, 2024 Tuyishime H, Claure RE, Balakrishnan K, et al. Impact of a daily huddle on safety in perioperative services. Jt Comm J Qual Patient Saf. 2024;50(9):678-683. doi:10.1016/j.jcjq.2024.04.012. https://psnet.ahrq.gov/issue/impact-daily-huddle-s… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45251/psn-pdfAugust 24, 2016 - 5 cataract surgeries, 5 people blinded: what went wrong? August 24, 2016 Kowalczyk L. Boston Globe. August 14, 2016. https://psnet.ahrq.gov/issue/5-cataract-surgeries-5-people-blinded-what-went-wrong Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series o… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60878/psn-pdfJanuary 01, 2021 - Intervention study for the reduction of medication errors in elderly trauma patients. September 2, 2020 Parro Martín M de los Á, Muñoz García M, Delgado Silveira E, et al. Intervention study for the reduction of medication errors in elderly trauma patients. J Eval Clin Pract. 2021;27(1):160-166. doi:10.1111/jep.134… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46374/psn-pdfAugust 30, 2017 - Structured patient handoffs: the movement toward adverse event reduction in the perioperative unit. August 30, 2017 Hamilton WL. https://psnet.ahrq.gov/issue/structured-patient-handoffs-movement-toward-adverse-event-reduction- perioperative-unit Miscommunication during care transitions can contribute to medical e… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44554/psn-pdfNovember 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… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837626/psn-pdfJuly 06, 2022 - Frailty, gaps in care coordination, and preventable adverse events. July 6, 2022 Akinyelure OP, Colvin CL, Sterling MR, et al. Frailty, gaps in care coordination, and preventable adverse events. BMC Geriatr. 2022;22(1):476. doi:10.1186/s12877-022-03164-7. https://psnet.ahrq.gov/issue/frailty-gaps-care-coordination… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47958/psn-pdfJune 26, 2019 - Patient safety professionals as the third victims of adverse events. June 26, 2019 Holden J, Card AJ. Patient safety professionals as the third victims of adverse events. J Patient Saf Risk Manag. 2019;24(4):166-175. doi:10.1177/2516043519850914. https://psnet.ahrq.gov/issue/patient-safety-professionals-third-vict… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47060/psn-pdfApril 25, 2018 - Patient safety vulnerabilities for children with intellectual disability in hospital: a systematic review and narrative synthesis. April 25, 2018 Mimmo L, Harrison R, Hinchcliff R. Patient safety vulnerabilities for children with intellectual disability in hospital: a systematic review and narrative synthesis. BMJ… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46712/psn-pdfDecember 21, 2018 - Analgesic-related medication errors reported to US Poison Control Centers. December 21, 2018 Eluri M, Spiller HA, Casavant MJ, et al. Analgesic-Related Medication Errors Reported to US Poison Control Centers. Pain Med. 2018;19(12):2357-2370. doi:10.1093/pm/pnx272. https://psnet.ahrq.gov/issue/analgesic-related-med… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42741/psn-pdfMarch 04, 2015 - Impact of an automated email notification system for results of tests pending at discharge: a cluster- randomized controlled trial. March 4, 2015 Dalal A, Roy CL, Poon EG, et al. Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial. J Am … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42674/psn-pdfSeptember 12, 2016 - Using crew resource management and a 'read-and-do checklist' to reduce failure-to-rescue events on a step- down unit. September 12, 2016 Young-Xu Y, Fore AM, Metcalf A, et al. Using crew resource management and a 'read-and-do checklist' to reduce failure-to-rescue events on a step-down unit. Am J Nurs. 2013;113(9)… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38519/psn-pdfMarch 25, 2009 - Work hours, work stress, and collaboration among ward staff in relation to risk of hospital-associated infection among patients. March 25, 2009 Virtanen M, Kurvinen T, Terho K, et al. Work hours, work stress, and collaboration among ward staff in relation to risk of hospital-associated infection among patients. Me… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46148/psn-pdfMay 31, 2017 - Implementation of a structured hospital-wide morbidity and mortality rounds model. May 31, 2017 Kwok ESH, Calder LA, Barlow-Krelina E, et al. Implementation of a structured hospital-wide morbidity and mortality rounds model. BMJ Qual Saf. 2017;26(6):439-448. doi:10.1136/bmjqs-2016-005459. https://psnet.ahrq.gov/is… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/850341/psn-pdfJune 14, 2023 - Impact of fatigue on anaesthesia providers: a scoping review. June 14, 2023 Scholliers A, Cornelis S, Tosi M, et al. Impact of fatigue on anaesthesia providers: a scoping review. Br J Anaesth. 2023;130(5):622-635. doi:10.1016/j.bja.2022.12.011. https://psnet.ahrq.gov/issue/impact-fatigue-anaesthesia-providers-scop… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47213/psn-pdfJune 20, 2018 - Are second victims getting the help they need? June 20, 2018 Headley M. Patient Saf Qual Healthc. May/June 2018. https://psnet.ahrq.gov/issue/are-second-victims-getting-help-they-need Clinicians can experience emotional stress, guilt, and insecurity after making a mistake. Organizations are increasingly building p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39517/psn-pdfMay 25, 2010 - A prospective controlled trial of the effect of a multi- faceted intervention on early recognition and intervention in deteriorating hospital patients. May 25, 2010 Mitchell IA, McKay H, Van Leuvan C, et al. A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and inter… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44890/psn-pdfJuly 11, 2017 - The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting. July 11, 2017 Her QL, Amato MG, Seger DL, et al. The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting. J Am Med Inform Assoc. 2016;23(5):924-33. doi:10.1093/jamia/ocv181. http…
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