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2001. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846457/psn-pdf
      March 22, 2023 - Feds move to rein in prior authorization, a system that harms and frustrates patients. March 22, 2023 Sausser L. Kaiser Health News. March 13, 2023. https://psnet.ahrq.gov/issue/feds-move-rein-prior-authorization-system-harms-and-frustrates-patients Lack of access to appropriate testing, procedures, and medication…

2002. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838139/psn-pdf
      September 21, 2022 - Error traps in acute pain management in children. September 21, 2022 Vecchione TM, Agarwal R, Monitto CL. Error traps in acute pain management in children. Paediatr Anaesth. 2022;32(9):982-992. doi:10.1111/pan.14514. https://psnet.ahrq.gov/issue/error-traps-acute-pain-management-children Appropriate pediatric pain…

2003. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38546/psn-pdf
      June 16, 2009 - Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error. June 16, 2009 Okon TR, Lutz PS, Liang H. Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error. J Pain Symptom Manage. 2009;37(6):1039-49. doi:10.1016/j.j…

2004. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849130/psn-pdf
      May 17, 2023 - Comparing perspectives on organisational silence: an analysis of the Gosport inquiry. May 17, 2023 Powell M. J Health Org Manag. 2023;37(1):67-83. https://psnet.ahrq.gov/issue/comparing-perspectives-organisational-silence-analysis-gosport-inquiry Individual, team, and organizational willingness to identify and add…

2005. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33830/psn-pdf
      March 22, 2016 - The epidemic of deaths due to prescription opioids—most of which occur in the outpatient setting—demonstrates

2006. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854637/psn-pdf
      October 18, 2023 - A scoping review of clinical handover mnemonic devices. October 18, 2023 Yung AHW, Pak CS, Watson B. A scoping review of clinical handover mnemonic devices. Int J Qual Health Care. 2023;35(3):mzad065. doi:10.1093/intqhc/mzad065. https://psnet.ahrq.gov/issue/scoping-review-clinical-handover-mnemonic-devices Cogniti…

2007. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46254/psn-pdf
      October 09, 2017 - Using risk stratification to reduce medical errors in cervical cancer prevention. October 9, 2017 Perkins RB, Cain JM, Feldman S. Using Risk Stratification to Reduce Medical Errors in Cervical Cancer Prevention. JAMA Intern Med. 2017;177(10):1411-1412. doi:10.1001/jamainternmed.2017.3999. https://psnet.ahrq.gov/is…

2008. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42663/psn-pdf
      October 16, 2023 - Patient Safety: A Case-based Innovative Playbook for Safer Care. Second Edition. October 16, 2023 Agrawal A, Bhatt J, eds. Cham, Switzerland, Springer Nature; 2023. ISBN: 9783031359330. https://psnet.ahrq.gov/issue/patient-safety-case-based-innovative-playbook-safer-care-second-edition This publication describes a…

2009. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867021/psn-pdf
      October 23, 2024 - Blind Spots: When Medicine Gets It Wrong, and What It Means for Our Health. October 23, 2024 Makary M. Blind Spots: When Medicine Gets It Wrong, And What It Means For Our Health. New York, NY: Bloomsbury Publishing; 2024. ISBN 9781639735310. https://psnet.ahrq.gov/issue/blind-spots-when-medicine-gets-it-wrong-and-…

2010. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867754/psn-pdf
      March 12, 2025 - Decision fatigue in hospital settings: a scoping review. March 12, 2025 Perry K, Jones S, Stumpff JC, et al. Decision fatigue in hospital settings: a scoping review. J Hosp Med. 2024;Epub Nov 11. doi:10.1002/jhm.13550. https://psnet.ahrq.gov/issue/decision-fatigue-hospital-settings-scoping-review Production pressu…

2011. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60186/psn-pdf
      April 01, 2020 - Eleven basic procedures/practices for dental patient safety. April 1, 2020 Perea-Pérez B, Labajo-González E, Acosta-Gío AE, et al. Eleven basic procedures/practices for dental patient safety. J Patient Saf. 2020;16(1). doi:10.1097/pts.0000000000000234. https://psnet.ahrq.gov/issue/eleven-basic-procedurespractices-…

2012. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48045/psn-pdf
      June 05, 2019 - Obstetric practice guidelines: labor's love lost? June 5, 2019 Cohen WR, Friedman EA. Obstetric practice guidelines: labor's love lost? J Matern Fetal Neonatal Med. 2019;32(9):1567-1570. doi:10.1080/14767058.2017.1406474. https://psnet.ahrq.gov/issue/obstetric-practice-guidelines-labors-love-lost Guidelines play a…

2013. States Targeting Reduction in Infections via Engagement (STRIVE). | PSNet
      psnet.ahrq.gov/issue/states-targeting-reduction-infections-engagement-strive
      June 12, 2024 - Special or Theme Issue States Targeting Reduction in Infections via Engagement (STRIVE). Citation Text: States Targeting Reduction in Infections via Engagement (STRIVE). Ann Intern Med. 2019;171(7_Suppl):s1-s82. Copy Citation Save Save to your library Prin…

2014. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41635/psn-pdf
      January 18, 2013 - Improvement in the detection of adverse drug events by the use of electronic health and prescription records: an evaluation of two trigger tools. January 18, 2013 Nwulu U, Nirantharakumar K, Odesanya R, et al. Improvement in the detection of adverse drug events by the use of electronic health and prescription reco…

2015. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851067/psn-pdf
      June 28, 2023 - Assessing medication safety in settings not designated solely for pediatric patients. June 28, 2023 ISMP Medication Safety Alert! Acute care edition. June 15, 2023;28(12);1-5. https://psnet.ahrq.gov/issue/assessing-medication-safety-settings-not-designated-solely-pediatric-patients Pediatric patients are at increa…

2016. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47217/psn-pdf
      June 27, 2018 - Drug shortages roundtable: minimizing the impact on patient care. June 27, 2018 Drug shortages roundtable: Minimizing the impact on patient care. Am J Health Syst Pharm. 2018;75(11):816-820. doi:10.2146/ajhp180048. https://psnet.ahrq.gov/issue/drug-shortages-roundtable-minimizing-impact-patient-care This commenta…

2017. Patient Safety in Primary Care | PSNet
      psnet.ahrq.gov/perspective/patient-safety-primary-care
      January 31, 2020 - These predominantly relate to inconsistent practices driving the prescribing of opioids and antibiotics

2018. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46861/psn-pdf
      February 28, 2018 - Special K with no license to kill: accidental ketamine overdose on induction of general anesthesia. February 28, 2018 Warner LL, Smischney N. Accidental Ketamine Overdose on Induction of General Anesthesia. Am J Case Rep. 2018;19:10-12. https://psnet.ahrq.gov/issue/special-k-no-license-kill-accidental-ketamine-ove…

2019. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866323/psn-pdf
      July 17, 2024 - AHRQ-Funded Patient Safety Project Highlights: Improving Patient Safety by Enhancing Care Coordination. July 17, 2024 Rockville, MD: Agency for Healthcare Research and Quality; June 2024. AHRQ Pub. No. 24-0017-2-EF. https://psnet.ahrq.gov/issue/ahrq-funded-patient-safety-project-highlights-improving-patient-safety…

2020. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866108/psn-pdf
      June 12, 2024 - Child age and risk of medication error: a multisite children's hospital study. June 12, 2024 Badgery-Parker T, Li L, Fitzpatrick E, et al. Child age and risk of medication error: a multisite children's hospital study. J Pediatr. 2024;272:114087. doi:10.1016/j.jpeds.2024.114087. https://psnet.ahrq.gov/issue/child-a…