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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45695/psn-pdfDecember 14, 2016 - Significant reduction in preanalytical errors for nonphlebotomy blood draws after implementation of a novel integrated specimen collection module. December 14, 2016 Le RD, Melanson SEF, Petrides AK, et al. Significant Reduction in Preanalytical Errors for Nonphlebotomy Blood Draws After Implementation of a Novel I… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60541/psn-pdfMay 01, 2013 - Targeted versus universal decolonization to prevent ICU infection. May 1, 2013 Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265. doi:10.1056/nejmoa1207290. https://psnet.ahrq.gov/issue/targeted-versus-universal-decoloni… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40743/psn-pdfFebruary 01, 2019 - Radiation risks of diagnostic imaging and fluoroscopy. December 23, 2016 Sentinel Event Alert. August 24, 2011;47:1-4. (revised February 2019). https://psnet.ahrq.gov/issue/radiation-risks-diagnostic-imaging The Joint Commission issues Sentinel Event Alerts periodically to highlight emerging patient safety issues … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73449/psn-pdfJune 30, 2021 - Adverse events and emergency department opioid prescriptions in adolescents. June 30, 2021 Worsham CM, Woo J, Jena AB, et al. Adverse events and emergency department opioid prescriptions in adolescents. Health Aff (Millwood). 2021;40(6):970-978. doi:10.1377/hlthaff.2020.01762. https://psnet.ahrq.gov/issue/adverse-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72757/psn-pdfFebruary 17, 2021 - Prolonged diagnostic intervals as marker of missed diagnostic opportunities in bladder and kidney cancer patients with alarm features: a longitudinal linked data study. February 17, 2021 Zhou Y, Walter FM, Singh H, et al. Prolonged diagnostic intervals as marker of missed diagnostic opportunities in bladder and k… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73856/psn-pdfSeptember 22, 2021 - Implicit bias and caring for diverse populations: pediatric trainee attitudes and gaps in training. September 22, 2021 Barber Doucet H, Ward VL, Johnson TJ, et al. Implicit bias and caring for diverse populations: pediatric trainee attitudes and gaps in training. Clin Pediatr (Phila). 2021;60(9-10):408-417. doi:10… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47368/psn-pdfSeptember 12, 2018 - Using co-design to develop a collective leadership intervention for healthcare teams to improve safety culture. September 12, 2018 Ward ME, De Brún A, Beirne D, et al. Using Co-Design to Develop a Collective Leadership Intervention for Healthcare Teams to Improve Safety Culture. Int J Environ Res Public Health. 20… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60053/psn-pdfJanuary 01, 2021 - A review of adverse event reports from emergency departments in the Veterans Health Administration. March 18, 2020 Gill S, Mills PD, Watts BV, et al. A Review of Adverse Event Reports From Emergency Departments in the Veterans Health Administration. J Patient Saf. 2021;17(8):e898-e903. doi:10.1097/pts.0000000000000… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/61122/psn-pdfJanuary 01, 2022 - Implementing high-reliability organization principles into practice: a rapid evidence review. November 11, 2020 Veazie S, Peterson K, Bourne D, et al. Implementing high-reliability organization principles into practice: a rapid evidence review. J Patient Saf. 2022;18(1):e320-e328. doi:10.1097/pts.0000000000000768. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72648/psn-pdfJanuary 20, 2021 - Nurse burnout predicts self-reported medication administration errors in acute care hospitals. January 20, 2021 Montgomery AP, Azuero A, Baernholdt MB, et al. Nurse burnout predicts self-reported medication administration errors in acute care hospitals. J Healthc Qual. 2020;43(1):13-23. doi:10.1097/jhq.00000000000… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44773/psn-pdfJanuary 13, 2016 - A tool for the concise analysis of patient safety incidents. January 13, 2016 Pham JC, Hoffman C, Popescu I, et al. A Tool for the Concise Analysis of Patient Safety Incidents. Jt Comm J Qual Patient Saf. 2016;42(1):26-33. https://psnet.ahrq.gov/issue/tool-concise-analysis-patient-safety-incidents Once identified,… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/865487/psn-pdfApril 03, 2024 - Evaluation of the design and structure of electronic medication labels to improve patient health knowledge and safety: a systematic review. April 3, 2024 Saif S, Bui TTT, Srivastava G, et al. Evaluation of the design and structure of electronic medication labels to improve patient health knowledge and safety: a sy… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/851185/psn-pdfJuly 05, 2023 - Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017. July 5, 2023 Riester MR, Goyal P, Steinman MA, et al. Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017. J Gen Intern Med. 2023;38(6):1563-1566. doi:10.1007/s11606-022-07825- 6… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60317/psn-pdfMay 13, 2020 - The nurse's experience of decision-making processes in missed nursing care: a qualitative study. May 13, 2020 Abdelhadi N, Drach?Zahavy A, Srulovici E. The nurse’s experience of decision?making processes in missed nursing care: a qualitative study. J Adv Nurs. 2020;76(8):2161-2170. doi:10.1111/jan.14387. https://p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/61120/psn-pdfNovember 11, 2020 - Application of human factors methods to understand missed follow-up of abnormal test results. November 11, 2020 Rogith D, Satterly T, Singh H, et al. Application of human factors methods to understand missed follow-up of abnormal test results. Appl Clin Inform. 2020;11(05):692-698. doi:10.1055/s-0040-1716537. http… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837208/psn-pdfMay 25, 2022 - Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study. May 25, 2022 Umoren R, Kim S, Gray MM, et al. Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study. BMJ Lead. 2022;6(1):15-19. doi:10.1136/leader-2020-000407. https://psne… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41464/psn-pdfNovember 26, 2014 - Risk of unintentional overdose with non-prescription acetaminophen products. November 26, 2014 Wolf MS, King J, Jacobson K, et al. Risk of unintentional overdose with non-prescription acetaminophen products. J Gen Intern Med. 2012;27(12):1587-93. doi:10.1007/s11606-012-2096-3. https://psnet.ahrq.gov/issue/risk-uni… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44809/psn-pdfMarch 02, 2016 - Seniors managing multiple medications: using mixed methods to view the home care safety lens. March 2, 2016 Lang A, Macdonald M, Marck P, et al. Seniors managing multiple medications: using mixed methods to view the home care safety lens. BMC Health Serv Res. 2015;15:548. doi:10.1186/s12913-015-1193-5. https://psn… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/851353/psn-pdfJuly 12, 2023 - Caregiver and clinician perspectives on discharge medication counseling: a qualitative study. July 12, 2023 Carroll AR, Schlundt D, Bonnet K, et al. Caregiver and clinician perspectives on discharge medication counseling: a qualitative study. Hosp Pediatr. 2023;13(4):325-342. doi:10.1542/hpeds.2022-006937. https:/… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40191/psn-pdfMay 28, 2014 - The Value of Close Calls in Improving Patient Safety. May 28, 2014 Wu AW, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2011. ISBN: 9781599404158. https://psnet.ahrq.gov/issue/value-close-calls-improving-patient-safety Close calls (sometimes called near misses) pose unique challenges and opportunities when …
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