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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45492/psn-pdf
    September 28, 2016 - Understanding human over-reliance on technology. September 28, 2016 ISMP Medication Safety Alert! Acute Care Edition. September 8, 2016;21:1-4. https://psnet.ahrq.gov/issue/understanding-human-over-reliance-technology Over-reliance on technology can contribute to error due to user complacency. Reviewing how the ten…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47142/psn-pdf
    June 13, 2018 - Managing health IT risks: reflections and recommendations. June 13, 2018 Sujan M. Managing health IT risks: reflections and recommendations. J Innov Health Inform. 2018;25(1):952. doi:10.14236/jhi.v25i1.952. https://psnet.ahrq.gov/issue/managing-health-it-risks-reflections-and-recommendations Health information t…
  3. psnet.ahrq.gov/web-mm/preventable-rash
    October 01, 2012 - Preventable Rash Citation Text: McLean C. Preventable Rash. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49475/psn-pdf
    March 01, 2005 - Techno Trip March 1, 2005 Cook RI. Techno Trip. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/techno-trip The Case A 70-year-old woman was admitted to a community hospital after developing confusion and right-sided weakness. A CT scan of her brain showed an acute subdural hematoma. The hospital arranged a…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72807/psn-pdf
    March 03, 2021 - Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems. March 3, 2021 ISMP Medication Safety Alert! Acute care edition. February 11, 2021;26(3):1-4. https://psnet.ahrq.gov/issue/updated-guidance-needed-longstanding-large-volume-parenteral-lvp-labeling- and-packaging …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41968/psn-pdf
    February 19, 2013 - Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist. February 19, 2013 Greenstein EA, Arora V, Staisiunas PG, et al. Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist. BMJ Qual Saf. 2013;22(3):203-9. doi:10.1136/bmjqs-2012…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36658/psn-pdf
    May 27, 2011 - Potassium and phosphorus repletion in hospitalized patients: implications for clinical practice and the potential use of healthcare information technology to improve prescribing and patient safety. May 27, 2011 Hemstreet BA, Stolpman N, Badesch DB, et al. Potassium and phosphorus repletion in hospitalized patient…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836763/psn-pdf
    March 16, 2022 - Maternity Pre-arrival Instructions by 999 Call Handlers. March 16, 2022 Farnborough, UK: Healthcare Safety Investigation Branch; February 2022. https://psnet.ahrq.gov/issue/maternity-pre-arrival-instructions-999-call-handlers Pre-hospital emergency care can be vulnerable to timing, information, and task failures th…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46427/psn-pdf
    April 04, 2018 - Improving Diagnosis in Radiology—Progress and Proposals. April 4, 2018 Bruno MA, Johnson K, Argy N, Graber ML, eds. Diagnosis. 2017;4(3):111-191. https://psnet.ahrq.gov/issue/improving-diagnosis-radiology-progress-and-proposals Radiology plays a unique role in the determination of a diagnosis. Cognitive and system…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846762/psn-pdf
    March 29, 2023 - Hospital ‘black boxes’ put surgical practices under the microscope. March 29, 2023 Sadick B. Wall Street Journal. March 19, 2023. https://psnet.ahrq.gov/issue/hospital-black-boxes-put-surgical-practices-under-microscope Safety information systems that track action in real time can reveal a trove of data about how …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74860/psn-pdf
    February 23, 2022 - Is electronic health record safety a paradox? February 23, 2022 Harrington L. Is electronic health record safety a paradox? AACN Adv Crit Care. 2021;32(4):375-380. doi:10.4037/aacnacc2021406. https://psnet.ahrq.gov/issue/electronic-health-record-safety-paradox The usability of health information technology, such a…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48043/psn-pdf
    October 01, 2023 - Health Services Safety Investigations Body. October 1, 2023 Lytchett House, 13 Freeland Park, Wareham Road, Poole, Dorset, BH16 6FA. https://psnet.ahrq.gov/issue/health-services-safety-investigations-body Independent investigations examine system weaknesses in health care to inform improvement, reduce risk, and pr…
  13. psnet.ahrq.gov/web-mm/specimen-almost-lost
    September 21, 2022 - Specimen Almost Lost Citation Text: Hehe YK. Specimen Almost Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
  14. psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
    March 01, 2015 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay Citation Text: O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: G…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73515/psn-pdf
    August 01, 2022 - Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents July 28, 2021 https://psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing- home-residents Summary The MOQI seeks to reduce avoidable hospitalization among nursing home residents b…
  16. psnet.ahrq.gov/issue/people-processes-health-it-and-accurate-patient-identification
    April 11, 2018 - Newspaper/Magazine Article People, processes, health IT and accurate patient identification. Citation Text: People, processes, health IT and accurate patient identification. Quick Safety. October 1, 2018;(45):1-2. Copy Citation Save Save to your library Prin…
  17. psnet.ahrq.gov/issue/managing-costs-clinical-negligence-trusts
    March 28, 2018 - Book/Report Managing the Costs of Clinical Negligence in Trusts. Citation Text: Managing the Costs of Clinical Negligence in Trusts. Comptroller and Auditor General, Department of Health; London, UK: National Audit Office; 2017. ISBN: 9781786041395. Copy Citation Save …
  18. psnet.ahrq.gov/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error
    June 10, 2018 - Newspaper/Magazine Article Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error. Citation Text: Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error. ISMP Medication Safety Alert! Acute care edition. August 26, 2010;15:1…
  19. psnet.ahrq.gov/issue/diagnosis-interpreting-shadows
    June 29, 2016 - Book/Report Diagnosis: Interpreting the Shadows. Citation Text: Diagnosis: Interpreting the Shadows. Croskerry P, Cosby KS, Graber ML, Singh H. Boca Raton, FL: CRC Press; 2017. ISBN: 9781409432333. Copy Citation Save Save to your library Print Download P…
  20. psnet.ahrq.gov/issue/national-steering-committee-patient-safety
    December 24, 2008 - Multi-use Website National Steering Committee for Patient Safety. Citation Text: National Steering Committee for Patient Safety. Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement. Copy Citation Save Save to your library …

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