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5021. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865882/psn-pdf
      May 15, 2024 - Kentucky first state to decriminalize medical errors. May 15, 2024 Robertson R. MedPage Today. April 30, 2024. https://psnet.ahrq.gov/issue/kentucky-first-state-decriminalize-medical-errors Criminalization of medical error can have a chilling effect on the transparency needed to inform improvement. This news artic…

5022. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42811/psn-pdf
      December 11, 2013 - The Patient Education Materials Assessment Tool (PEMAT) and User's Guide: An Instrument to Assess the Understandability and Actionability of Print and Audiovisual Patient Education Materials. December 11, 2013 Rockville, MD: Agency for Healthcare Research and Quality; October 2013. https://psnet.ahrq.gov/issue/pa…

5023. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43680/psn-pdf
      November 19, 2014 - FDA Pharmacists Help Consumers Use Medicines Safely. November 19, 2014 Silver Spring, MD: United States Food and Drug Administration; October 31, 2014. https://psnet.ahrq.gov/issue/fda-pharmacists-help-consumers-use-medicines-safely Studies have shown that pharmacist involvement can prevent medication errors. To he…

5024. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43549/psn-pdf
      September 27, 2016 - Resident to resident handoffs in the emergency department: an observational study. September 27, 2016 Peterson SM, Gurses AP, Regan L. Resident to resident handoffs in the emergency department: an observational study. J Emerg Med. 2014;47(5):573-9. doi:10.1016/j.jemermed.2014.06.027. https://psnet.ahrq.gov/issue/r…

5025. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36745/psn-pdf
      March 10, 2011 - Reevaluating recovery: perceived violations and preemptive interventions on emergency psychiatry rounds. March 10, 2011 Cohen T, Blatter B, Almeida C, et al. Reevaluating recovery: perceived violations and preemptive interventions on emergency psychiatry rounds. J Am Med Inform Assoc. 2007;14(3):312-9. https://ps…

5026. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37154/psn-pdf
      September 02, 2015 - Health Literacy and Patient Safety: Help Patients Understand. Manual for Clinicians. 2nd ed. September 2, 2015 Weiss BD. Chicago, IL: American Medical Association Foundation; 2007. https://psnet.ahrq.gov/issue/health-literacy-and-patient-safety-help-patients-understand-manual-clinicians- 2nd-ed This book provides…

5027. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50805/psn-pdf
      January 15, 2020 - Advancing safety with closed-loop communication of test results. January 15, 2020 Quick Safety. December 17, 2019;(52):1-3. https://psnet.ahrq.gov/issue/advancing-safety-closed-loop-communication-test-results Incomplete or delayed test result communication is a known factor in diagnostic error. This article shares…

5028. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846765/psn-pdf
      March 29, 2023 - Addressing Medical Gaslighting to Improve Maternal Health—Together. March 29, 2023 Oregon Patient Safety Commission: 2023. https://psnet.ahrq.gov/issue/addressing-medical-gaslighting-improve-maternal-health-together Gaslighting has been identified as a contributor to maternal mortality and morbidity. This toolkit …

5029. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39262/psn-pdf
      March 04, 2011 - Unintended errors with EHR-based result management: a case series. March 4, 2011 Yackel TR, Embi P. Unintended errors with EHR-based result management: a case series. J Am Med Inform Assoc. 2010;17(1):104-7. doi:10.1197/jamia.M3294. https://psnet.ahrq.gov/issue/unintended-errors-ehr-based-result-management-case-se…

5030. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35614/psn-pdf
      March 10, 2011 - Overriding of drug safety alerts in computerized physician order entry. March 10, 2011 van der Sijs H, Aarts J, Vulto A, et al. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc. 2006;13(2):138-47. https://psnet.ahrq.gov/issue/overriding-drug-safety-alerts-computerized-p…

5031. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47049/psn-pdf
      July 10, 2019 - Injectable Opioid Shortages: Suggestions for Management and Conservation. July 10, 2019 University of Utah Drug Information Service; ASHP; American Society of Health-System Pharmacists. https://psnet.ahrq.gov/issue/injectable-opioid-shortages-suggestions-management-and-conservation Efforts to limit the availabilit…

5032. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35056/psn-pdf
      February 09, 2011 - Potential role of pharmacogenomics in reducing adverse drug reactions: a systematic review. February 9, 2011 Phillips KA, Veenstra DL, Oren E, et al. Potential role of pharmacogenomics in reducing adverse drug reactions: a systematic review. JAMA. 2001;286(18):2270-9. https://psnet.ahrq.gov/issue/potential-role-ph…

5033. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60998/psn-pdf
      October 07, 2020 - The slow, troubling death of the autopsy. October 7, 2020 Ashworth S. Elemental. September 22, 2020. https://psnet.ahrq.gov/issue/slow-troubling-death-autopsy The rate of autopsies – the “gold standard” of death investigation – are decreasing worldwide. This commentary highlights the lost opportunities for ho…

5034. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44155/psn-pdf
      June 24, 2015 - Patient Safety Tool Kit. June 24, 2015 WHO Regional Office for the Eastern Mediterranean. Cairo, Egypt: World Health Organization; 2015. ISBN: 9789290220596. https://psnet.ahrq.gov/issue/patient-safety-tool-kit Patient safety programs should reflect local needs, motivate clinician and leadership engagement, and s…

5035. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35615/psn-pdf
      March 11, 2011 - The development and evaluation of an integrated electronic prescribing and drug management system for primary care. March 11, 2011 Tamblyn R, Huang A, Kawasumi Y, et al. The development and evaluation of an integrated electronic prescribing and drug management system for primary care. J Am Med Inform Assoc. 2006;1…

5036. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35663/psn-pdf
      June 25, 2010 - Effects of critical care nurses' work hours on vigilance and patients' safety. June 25, 2010 Scott LD, Rogers AE, Hwang W-T, et al. Effects of critical care nurses' work hours on vigilance and patients' safety. Am J Crit Care. 2006;15(1):30-7. https://psnet.ahrq.gov/issue/effects-critical-care-nurses-work-hours-vi…

5037. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38506/psn-pdf
      February 10, 2015 - Implementation of computerized physician order entry in seven countries. February 10, 2015 Aarts J, Koppel R. Implementation of computerized physician order entry in seven countries. Health Aff (Millwood). 2009;28(2):404-414. doi:10.1377/hlthaff.28.2.404. https://psnet.ahrq.gov/issue/implementation-computerized-ph…

5038. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40733/psn-pdf
      August 31, 2011 - Beyond the prescription: medication monitoring and adverse drug events in older adults. August 31, 2011 Steinman MA, Handler S, Gurwitz JH, et al. Beyond the prescription: medication monitoring and adverse drug events in older adults. J Am Geriatr Soc. 2011;59(8):1513-1520. doi:10.1111/j.1532- 5415.2011.03500.x. …

5039. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867648/psn-pdf
      January 01, 2023 - Opioid Taskforce Playbook. January 1, 2023 College of Healthcare Information Management Executives; 2023. Opioid Taskforce Playbook. https://psnet.ahrq.gov/issue/opioid-taskforce-playbook Hospitals play an important role in identifying and preventing the misuse and abuse of prescription opioids. This Opioid Playbo…

5040. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40658/psn-pdf
      August 03, 2011 - Development and validation of a tool to improve paediatric referral/consultation communication. August 3, 2011 Stille CJ, Mazor KM, Meterko V, et al. Development and validation of a tool to improve paediatric referral/consultation communication. BMJ Qual Saf. 2011;20(8):692-7. doi:10.1136/bmjqs.2010.045781. https:…