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1561. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46524/psn-pdf
      October 18, 2017 - Pressure Injury Prevention in Hospitals Training Program. October 18, 2017 Rockville, MD: Agency for Healthcare Research and Quality; September 2017. https://psnet.ahrq.gov/issue/pressure-injury-prevention-hospitals-training-program Pressure ulcers are a common hospital-acquired condition that can lead to patient h…

1562. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72511/psn-pdf
      November 25, 2020 - Hospital Preparedness for a COVID-19 Surge: Assessment Tool. November 25, 2020 Boston, MA:  Institute for Healthcare Improvement; 2020. https://psnet.ahrq.gov/issue/hospital-preparedness-covid-19-surge-assessment-tool Hospital crisis management, preparation, and planning are of heightened interest due to the …

1563. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43740/psn-pdf
      December 10, 2014 - Participation in EHR based simulation improves recognition of patient safety issues. December 10, 2014 Stephenson LS, Gorsuch A, Hersh WR, et al. Participation in EHR based simulation improves recognition of patient safety issues. BMC Med Educ. 2014;14:224. doi:10.1186/1472-6920-14-224. https://psnet.ahrq.gov/issu…

1564. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38498/psn-pdf
      September 27, 2016 - Nursing time devoted to medication administration in long-term care: clinical, safety, and resource implications. September 27, 2016 Thomson MS, Gruneir A, Lee M, et al. Nursing time devoted to medication administration in long-term care: clinical, safety, and resource implications. J Am Geriatr Soc. 2009;57(2):266…

1565. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72761/psn-pdf
      February 17, 2021 - Using ventilator splitters during the COVID-19 pandemic-- letter to health care providers. February 17, 2021 Silver Spring, MD: Division of Industry and Consumer Education, US Food and Drug Administration; February 9. 2021. https://psnet.ahrq.gov/issue/using-ventilator-splitters-during-covid-19-pandemic-letter-hea…

1566. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44070/psn-pdf
      September 09, 2015 - Communication of vital signs at emergency department handoff: opportunities for improvement. September 9, 2015 Venkatesh AK, Curley D, Chang Y, et al. Communication of Vital Signs at Emergency Department Handoff: Opportunities for Improvement. Ann Emerg Med. 2015;66(2):125-30. doi:10.1016/j.annemergmed.2015.02.025…

1567. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/855002/psn-pdf
      November 01, 2023 - Temporarily holding medication orders safely in order to prevent patient harm. November 1, 2023 ISMP Medication Safety Alert! Acute care edition. October 19, 2023;28(21):1-4. https://psnet.ahrq.gov/issue/temporarily-holding-medication-orders-safely-order-prevent-patient-harm Process disconnects can cause administr…

1568. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837641/psn-pdf
      July 06, 2022 - Ambulatory medication safety in primary care: a systematic review. July 6, 2022 Young RA, Fulda KG, Espinoza A, et al. Ambulatory medication safety in primary care: a systematic review. J Am Board Fam Med. 2022;35(3):610-628. doi:10.3122/jabfm.2022.03.210334. https://psnet.ahrq.gov/issue/ambulatory-medication-safe…

1569. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60750/psn-pdf
      August 06, 2020 - Missed breast cancer: effects of subconscious bias and lesion characteristics. August 6, 2020 Lamb LR, Mohallem Fonseca M, Verma R, et al. Missed breast cancer: effects of subconscious bias and lesion characteristics. RadioGraphics. 2020;40(4):941-960. doi:10.1148/rg.2020190090. https://psnet.ahrq.gov/issue/missed…

1570. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47669/psn-pdf
      July 17, 2019 - Evaluating a handheld decision support device in pediatric intensive care settings. July 17, 2019 Reynolds TL, DeLucia PR, Esquibel KA, et al. JAMIA Open. 2019;2:49-61. https://psnet.ahrq.gov/issue/evaluating-handheld-decision-support-device-pediatric-intensive-care-settings This pre–post mixed-methods implementat…

1571. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44830/psn-pdf
      January 01, 2019 - Tune-in and time-out: toward surgeon-led prevention of "never" events. February 17, 2016 Jones N. Tune-In and Time-Out: Toward Surgeon-Led Prevention of "Never" Events. J Patient Saf. 2019;15(4):e36-e39. doi:10.1097/PTS.0000000000000259. https://psnet.ahrq.gov/issue/tune-and-time-out-toward-surgeon-led-prevention-…

1572. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46837/psn-pdf
      March 21, 2018 - Drug shortages: effect on parenteral nutrition therapy. March 21, 2018 Holcombe B, Mattox TW, Plogsted S. Drug Shortages: Effect on Parenteral Nutrition Therapy. Nutr Clin Pract. 2018;33(1):53-61. doi:10.1002/ncp.10052. https://psnet.ahrq.gov/issue/drug-shortages-effect-parenteral-nutrition-therapy Shortages of me…

1573. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43789/psn-pdf
      August 05, 2015 - Do cell phones belong in the operating room? August 5, 2015 Luthra S. Kaiser Health News. July 14, 2015. https://psnet.ahrq.gov/issue/do-cell-phones-belong-operating-room Distractions can lead to care and process omissions. Reporting on the prevalence of mobile technology in the operating room and how it can hinde…

1574. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45923/psn-pdf
      April 19, 2017 - Huddles and debriefings: improving communication on labor and delivery. April 19, 2017 McQuaid-Hanson E, Pian-Smith MCM. Huddles and Debriefings: Improving Communication on Labor and Delivery. Anesthesiol Clin. 2017;35(1):59-67. doi:10.1016/j.anclin.2016.09.006. https://psnet.ahrq.gov/issue/huddles-and-debriefings…

1575. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44410/psn-pdf
      August 12, 2015 - Workarounds in the workplace: a second look. August 12, 2015 Seaman JB, Erlen JA. Workarounds in the Workplace: A Second Look. Orthop Nurs. 2015;34(4):235-242. doi:10.1097/NOR.0000000000000161. https://psnet.ahrq.gov/issue/workarounds-workplace-second-look Workarounds are prevalent in health care and create opport…

1576. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50556/psn-pdf
      January 01, 2021 - The compliance with a patient safety bundle for management of placenta accreta spectrum. October 16, 2019 Quist-Nelson J, Crank A, Oliver EA, et al. The compliance with a patient-safety bundle for management of placenta accreta spectrum†. J Matern Fetal Neonatal Med. 2021;34(17):2880-2886. doi:10.1080/14767058.201…

1577. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40011/psn-pdf
      November 17, 2010 - Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates. November 17, 2010 Lin MY, Hota B, Khan YM, et al. Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates. JAMA. 2010;304(18):2035-41. doi:10.1001/jama.2010.1637. https://p…

1578. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43095/psn-pdf
      April 09, 2014 - Intravenous chemotherapy preparation errors: patient safety risks identified in a pan-Canadian exploratory study. April 9, 2014 White R, Cassano-Piché A, Fields A, et al. Intravenous chemotherapy preparation errors: patient safety risks identified in a pan-Canadian exploratory study. J Oncol Pharm Pract. 2014;20(1…

1579. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73631/psn-pdf
      August 25, 2021 - Patient harm from cardiovascular medications. August 25, 2021 Paradissis C, Cottrell N, Coombes ID, et al. Patient harm from cardiovascular medications. Ther Adv Drug Saf. 2021;12:204209862110274. doi:10.1177/20420986211027451. https://psnet.ahrq.gov/issue/patient-harm-cardiovascular-medications Adverse drug event…

1580. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837155/psn-pdf
      November 15, 2022 - Advancing Diagnostic Excellence for Older Adults: Proceedings of a Workshop in Brief. November 15, 2022  National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. ISBN 9780309696333.  https://psnet.ahrq.gov/issue/advancing-diagnostic-excellence-ol…