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7301. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44559/psn-pdf
      April 15, 2016 - Diagnostic errors related to acute abdominal pain in the emergency department. April 15, 2016 Medford-Davis L, Park E, Shlamovitz G, et al. Diagnostic errors related to acute abdominal pain in the emergency department. Emerg Med J. 2016;33(4):253-9. doi:10.1136/emermed-2015-204754. https://psnet.ahrq.gov/issue/dia…

7302. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42085/psn-pdf
      March 13, 2013 - In-facility delirium programs as a patient safety strategy: a systematic review. March 13, 2013 Reston JT, Schoelles KM. In-facility delirium prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):375-80. doi:10.7326/0003-4819-158-5-201303051-00003. https://psnet.ah…

7303. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43355/psn-pdf
      July 23, 2014 - Nearing zero...reducing grade C medication errors. July 23, 2014 Cockerham J, Figueroa-Altmann A, Foxen C, et al. Nearing zero..reducing grade C medication errors. Nurs Manage. 2014;45(7):26-31. doi:10.1097/01.NUMA.0000451033.38845.d3. https://psnet.ahrq.gov/issue/nearing-zeroreducing-grade-c-medication-errors Thi…

7304. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38977/psn-pdf
      September 30, 2009 - Enhanced end-of-life care associated with deploying a rapid response team: a pilot study. September 30, 2009 Vazquez R, Gheorghe C, Grigoriyan A, et al. Enhanced end-of-life care associated with deploying a rapid response team: a pilot study. J Hosp Med. 2009;4(7):449-52. doi:10.1002/jhm.451. https://psnet.ahrq.go…

7305. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45046/psn-pdf
      July 05, 2016 - Diagnosing sepsis is subjective and highly variable: a survey of intensivists using case vignettes. July 5, 2016 Rhee C, Kadri SS, Danner RL, et al. Diagnosing sepsis is subjective and highly variable: a survey of intensivists using case vignettes. Crit Care. 2016;20:89. doi:10.1186/s13054-016-1266-9. https://psne…

7306. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39356/psn-pdf
      April 08, 2011 - Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations. April 8, 2011 Thomas EJ, Williams AL, Reichman EF, et al. Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations. Pediatrics. 2010;125(3):539-546. doi:10.1542/ped…

7307. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74196/psn-pdf
      December 15, 2021 - Adverse glycemic events and critical emergencies. December 15, 2021 ISMP Medication Safety Alert! Acute care edition. December 2, 2021;(24)1-4. https://psnet.ahrq.gov/issue/adverse-glycemic-events-and-critical-emergencies Insulin is a high-alert medication that requires extra attention to safely manage blood sugar …

7308. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837706/psn-pdf
      July 20, 2022 - Are opioid infusions used inappropriately at end of life? Results from a quality/safety project. July 20, 2022 Yeh JC, Chae SG, Kennedy PJ, et al. Are opioid infusions used inappropriately at end of life? Results from a quality/safety project. J Pain Symptom Manage. 2022;64(3):e133-e138. doi:10.1016/j.jpainsymman.…

7309. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45143/psn-pdf
      October 20, 2016 - Medical improv: a novel approach to teaching communication and professionalism skills. October 20, 2016 Watson K, Fu B. Medical Improv: A Novel Approach to Teaching Communication and Professionalism Skills. Ann Intern Med. 2016;165(8):591-592. doi:10.7326/M15-2239. https://psnet.ahrq.gov/issue/medical-improv-novel…

7310. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60711/psn-pdf
      July 22, 2020 - Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study. July 22, 2020 Maa T, Scherzer DJ, Harwayne-Gidansky I, et al. Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study. J Allergy Clin Immunol Pract. 2020;8(4):1239-1246.e3. doi:10.1016/j.jaip.…

7311. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73429/psn-pdf
      June 23, 2021 - Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. June 23, 2021 Farnborough, UK: Healthcare Safety Investigation Branch; June 2021. https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings Wrong site/wrong patent surgery is a persisten…

7312. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45925/psn-pdf
      April 19, 2017 - All consumer medication information is not created equal: implications for medication safety. April 19, 2017 Monkman H, Kushniruk AW. All Consumer Medication Information Is Not Created Equal: Implications for Medication Safety. Stud Health Technol Inform. 2017;234:233-237. https://psnet.ahrq.gov/issue/all-consumer…

7313. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45270/psn-pdf
      June 29, 2016 - Using contemporary leadership skills in medication safety programs. June 29, 2016 Hertig JB, Hultgren KE, Weber RJ. Using Contemporary Leadership Skills in Medication Safety Programs. Hosp Pharm. 2016;51(4):338-44. doi:10.1310/hpj5104-338. https://psnet.ahrq.gov/issue/using-contemporary-leadership-skills-medicatio…

7314. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43459/psn-pdf
      August 27, 2014 - Serious Reportable Events. August 27, 2014 Nova Scotia Department of Health and Wellness. https://psnet.ahrq.gov/issue/serious-reportable-events Incident reporting systems are an important method for capturing, analyzing, and learning about a broad range of potential safety issues. This Web site provides access to…

7315. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46928/psn-pdf
      May 16, 2018 - Serious incidents after death: content analysis of incidents reported to a national database. May 16, 2018 Yardley IE, Carson-Stevens A, Donaldson LJ. Serious incidents after death: content analysis of incidents reported to a national database. J R Soc Med. 2017;111(2):57-64. doi:10.1177/0141076817744561. https://…

7316. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47656/psn-pdf
      March 13, 2019 - Sleep and alertness in a duty-hour flexibility trial in internal medicine. March 13, 2019 Basner M, Asch DA, Shea JA, et al; iCOMPARE Research Group. N Engl J Med. 2019;380:915-923. https://psnet.ahrq.gov/issue/sleep-and-alertness-duty-hour-flexibility-trial-internal-medicine This cluster-randomized trial compared…

7317. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46977/psn-pdf
      April 04, 2018 - Latex: a lingering and lurking safety risk. April 4, 2018 Liberatore K. PA-PSRS Patient Saf Advis. 2018 March;15. https://psnet.ahrq.gov/issue/latex-lingering-and-lurking-safety-risk Latex products are widely available in hospitals and represent a persistent threat to patients with latex allergies. Drawing from 61…

7318. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44428/psn-pdf
      November 20, 2015 - Test result communication in primary care: a survey of current practice. November 20, 2015 Litchfield I, Bentham L, Lilford RJ, et al. Test result communication in primary care: a survey of current practice. BMJ Qual Saf. 2015;24(11):691-9. doi:10.1136/bmjqs-2014-003712. https://psnet.ahrq.gov/issue/test-result-co…

7319. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46776/psn-pdf
      February 28, 2018 - Older adults' awareness of deprescribing: a population- based survey. February 28, 2018 Turner JP, Tannenbaum C. Older adults' awareness of deprescribing: a population-based survey. J Am Geriatr Soc. 2017;65(12):2691-2696. doi:10.1111/jgs.15079. https://psnet.ahrq.gov/issue/older-adults-awareness-deprescribing-pop…

7320. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865346/psn-pdf
      March 27, 2024 - RaDonda Vaught says some system practices contributed to fatal mistake. March 27, 2024 Clark C. MedPage Today. March 14, 2024. https://psnet.ahrq.gov/issue/vaught-says-some-system-practices-contributed-fatal-mistake Stories from clinicians involved in errors provide unique insights into both the human an…