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  1. 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-…

  2. 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…

  3. 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…

  4. 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…

  5. 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…

  6. 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…

  7. 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…

  8. 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…

  9. 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…

  10. 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…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45454/psn-pdf
    September 04, 2016 - Headline-grabbing study brings attention back to medical errors. September 4, 2016 Abbasi J. Headline-Grabbing Study Brings Attention Back to Medical Errors. JAMA. 2016;316(7):698-700. doi:10.1001/jama.2016.8073. https://psnet.ahrq.gov/issue/headline-grabbing-study-brings-attention-back-medical-errors The presenc…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47855/psn-pdf
    June 19, 2019 - Medication Overload: America's Other Drug Problem. June 19, 2019 Brownlee S; Garber J. Brookline, MA: Lown Institute; 2019. https://psnet.ahrq.gov/issue/medication-overload-americas-other-drug-problem Overprescribing is a common problem that contributes to patient harm. This report examines financial, clinical, an…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866118/psn-pdf
    June 12, 2024 - Factors Affecting the Delivery of Safe Care in Midwifery Units. June 12, 2024 Maternity and Newborn Safety Investigations Programme. Newcastle Upon Tyne, UK: Care Quality Commission; May 2024. https://psnet.ahrq.gov/issue/factors-affecting-delivery-safe-care-midwifery-units Safe maternal care is a challenge world…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42913/psn-pdf
    January 29, 2014 - What to do with healthcare incident reporting systems. January 29, 2014 Pham JC, Girard T, Pronovost PJ. What to do with healthcare Incident Reporting Systems. J Public Health Res. 2013;2(3). doi:10.4081/jphr.2013.e27. https://psnet.ahrq.gov/issue/what-do-healthcare-incident-reporting-systems Incident reporting sy…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73189/psn-pdf
    April 28, 2021 - Time out! Rethinking surgical safety: more than just a checklist. April 28, 2021 Weinger MB. Time out! Rethinking surgical safety: more than just a checklist. BMJ Qual Saf. 2021;30(8):613-617. doi:10.1136/bmjqs-2020-012600. https://psnet.ahrq.gov/issue/time-out-rethinking-surgical-safety-more-just-checklist Check…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44396/psn-pdf
    January 22, 2016 - Bedside shift-to-shift handoffs: a systematic review of the literature. January 22, 2016 Mardis T, Mardis M, Davis JJ, et al. Bedside Shift-to-Shift Handoffs: A Systematic Review of the Literature. J Nurs Care Qual. 2016;31(1):54-60. doi:10.1097/NCQ.0000000000000142. https://psnet.ahrq.gov/issue/bedside-shift-shif…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73668/psn-pdf
    September 01, 2021 - Leadership: an effective human factor during COVID-19. September 1, 2021 Dhahri AA, Refson J. Leadership: an effective human factor during COVID-19. BMJ Leader. 2021;5:203- 205. doi:10.1136/leader-2020-000384. https://psnet.ahrq.gov/issue/leadership-effective-human-factor-during-covid-19 Hierarchy and professional…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72534/psn-pdf
    December 02, 2020 - Patients' perceptions of safety in emergency medical services: an interview study. December 2, 2020 Venesoja A, Castrén M, Tella S, et al. Patients’ perceptions of safety in emergency medical services: an interview study. BMJ Open. 2020;10(10):e037488. doi:10.1136/bmjopen-2020-037488. https://psnet.ahrq.gov/issue/…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38938/psn-pdf
    July 26, 2023 - ISMP's List of Confused Drug Names. July 26, 2023 Horsham, PA; Institute for Safe Medication Practices: July 2023. https://psnet.ahrq.gov/issue/ismps-list-confused-drug-names Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet provides a comprehensive list of commonly…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41273/psn-pdf
    June 01, 2012 - Minimizing inappropriate medications in older populations: a ten-step conceptual framework. June 1, 2012 Scott IA, Gray LC, Martin J, et al. Minimizing inappropriate medications in older populations: a 10-step conceptual framework. Am J Med. 2012;125(6):529-37.e4. doi:10.1016/j.amjmed.2011.09.021. https://psnet.ah…
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