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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45286/psn-pdf
    May 07, 2018 - Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility. May 7, 2018 ISMP Medication Safety Alert! Acute Care Edition. June 16, 2016;21:1-6. https://psnet.ahrq.gov/issue/paralyzed-mistakes-reassess-safety-neuromuscular-blockers-your-facility Neuromuscular blockers can result in seriou…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45679/psn-pdf
    January 03, 2018 - Global Guidelines on the Prevention of Surgical Site Infection. January 3, 2018 Global Guidelines on the Prevention of Surgical Site Infection. https://psnet.ahrq.gov/issue/global-guidelines-prevention-surgical-site-infection Efforts to reduce surgical site infections have achieved some success. The World Health O…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42996/psn-pdf
    March 19, 2014 - The "physician-led chart audit": engaging providers in fortifying a culture of safety. March 19, 2014 Gitkind MJ, Perla RJ, Manno M, et al. The "physician-led chart audit: " engaging providers in fortifying a culture of safety. J Patient Saf. 2014;10(1):72-9. doi:10.1097/PTS.0000000000000057. https://psnet.ahrq.go…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46239/psn-pdf
    January 01, 2021 - Identifying high-alert medications in a university hospital by applying data from the medication error reporting system. August 16, 2017 Tyynismaa L, Honkala A, Airaksinen M, et al. Identifying High-alert Medications in a University Hospital by Applying Data From the Medication Error Reporting System. J Patient Sa…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44072/psn-pdf
    August 02, 2015 - The rise of the medical scribe industry: implications for the advancement of electronic health records. August 2, 2015 Gellert GA, Ramirez R, Webster L. The rise of the medical scribe industry: implications for the advancement of electronic health records. JAMA. 2015;313(13):1315-1316. doi:10.1001/jama.2014.17128. …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35023/psn-pdf
    March 04, 2011 - Building a framework for trust: critical event analysis of deaths in surgical care. March 4, 2011 Thompson A, Stonebridge PA. Building a framework for trust: critical event analysis of deaths in surgical care. BMJ. 2005;330(7500):1139-42. https://psnet.ahrq.gov/issue/building-framework-trust-critical-event-analysi…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44512/psn-pdf
    September 23, 2015 - Increased mortality associated with weekend hospital admission: a case for expanded seven day services? September 23, 2015 Freemantle N, Ray D, McNulty D, et al. Increased mortality associated with weekend hospital admission: a case for expanded seven day services? BMJ. 2015;351:h4596. doi:10.1136/bmj.h4596. https…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45634/psn-pdf
    January 11, 2017 - Operating room traffic as a modifiable risk factor for surgical site infection. January 11, 2017 Wanta BT, Glasgow AE, Habermann EB, et al. Operating Room Traffic as a Modifiable Risk Factor for Surgical Site Infection. Surg Infect (Larchmt). 2016;17(6):755-760. https://psnet.ahrq.gov/issue/operating-room-traffic-…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47355/psn-pdf
    September 05, 2018 - Preventing medication errors in the information age. September 5, 2018 Godshall M, Riehl M. Preventing medication errors in the information age. Nursing (Brux). 2018;48(9):56- 58. doi:10.1097/01.NURSE.0000544230.51598.38. https://psnet.ahrq.gov/issue/preventing-medication-errors-information-age Failure to consider…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45941/psn-pdf
    March 08, 2017 - Medication errors associated with transition from insulin pens to insulin vials. March 8, 2017 Trimble AN, Bishop B, Rampe N. Medication errors associated with transition from insulin pens to insulin vials. Am J Health Syst Pharm. 2017;74(2):70-75. doi:10.2146/ajhp150726. https://psnet.ahrq.gov/issue/medication-er…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47850/psn-pdf
    March 27, 2019 - Medicines-related harm in the elderly post-hospital discharge. March 27, 2019 Cheong V-L, Tomlinson J, Khan S, et al. Prescriber. 2019;30:29-34. https://psnet.ahrq.gov/issue/medicines-related-harm-elderly-post-hospital-discharge Geriatric patients are particularly vulnerable to medication-related harm. This articl…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34780/psn-pdf
    March 28, 2005 - Disseminating innovations in health care. March 28, 2005 Berwick DM. Disseminating Innovations in Health Care. JAMA. 2003;289(15):1969-1975. doi:10.1001/jama.289.15.1969. https://psnet.ahrq.gov/issue/disseminating-innovations-health-care This commentary and review discusses the ability to adopt growing numbers of …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46413/psn-pdf
    February 22, 2018 - A comparison of error rates between intravenous push methods: a prospective, multisite, observational study. February 22, 2018 Hertig JB, Degnan DD, Scott CR, et al. A Comparison of Error Rates Between Intravenous Push Methods: A Prospective, Multisite, Observational Study. J Patient Saf. 2018;14(1):60-65. doi:10.…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866647/psn-pdf
    September 04, 2024 - Diagnostic discrepancies in the emergency department: a retrospective study. September 4, 2024 Schols LA, Maranus ME, Rood PPM, et al. Diagnostic discrepancies in the emergency department: a retrospective study. J Patient Saf. 2024;20(6):420-425. doi:10.1097/pts.0000000000001252. https://psnet.ahrq.gov/issue/diagn…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866446/psn-pdf
    August 07, 2024 - FDA alerts health care providers, compounders and patients of dosing errors associated with compounded injectable semaglutide products. August 7, 2024 FDA alerts health care providers, compounders and patients of dosing errors associated with compounded injectable semaglutide products.July 26, 2024; https://psnet…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46760/psn-pdf
    January 24, 2018 - Systematic evidence review of rates and burden of harm of intravenous admixture drug preparation errors in healthcare settings. January 24, 2018 Hedlund N, Beer I, Hoppe-Tichy T, et al. Systematic evidence review of rates and burden of harm of intravenous admixture drug preparation errors in healthcare settings. B…

  17. Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx Spotlight A Missed Bowel Perforation – the Importance of Diagnostic Reasoning Source and Credits • This presentation is based on the September 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/web…

  18. PSNet Curated Library (pdf file)

    psnet.ahrq.gov/print/pdf/node/848754
    January 01, 2025 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Implementation of Patient Safety Projects Curated Library Foundations Leading change: why transformation efforts fail. Kotter JP. Harvard Bus Rev  1995;73(2);59-67. Kotter, a professor at Harvard Business School, outlines the eight stages …

  19. A Laceration that Needed a Proper Exam, Not an X-Ray | PSNet

    psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
    November 25, 2020 - SPOTLIGHT CASE A Laceration that Needed a Proper Exam, Not an X-Ray Citation Text: Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Cit…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45626/psn-pdf
    October 29, 2017 - The impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic order sets for monitoring oral chemotherapy. October 29, 2017 Battis B, Clifford L, Huq M, et al. The impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic order sets for monitoring oral chem…
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