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psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - January 22, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news … Maintaining hand hygiene is a critical safety activity for patients, families, and healthcare workers … Commentary
AI: promise or peril for patient safety. … Patients for Patient Safety US (PFPS-US) is a patient- and family-led organization to improve healthcare … safety, equitable healthcare, and patient outcomes.
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psnet.ahrq.gov/issue/hospital-bracelets-face-hurdles-they-fix-hazard
August 15, 2012 - This news article reports on the dynamic between patient safety and privacy in the use of color-coded … bracelets that indicate patient preferences related to end-of-life care. … September 24, 2014
At Bellevue, a desperate fight to ensure the patients' safety. … November 11, 2015
Overkill: An avalanche of unnecessary medical care is harming patients … July 23, 2008
Standardising wristbands improves patient safety.
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psnet.ahrq.gov/node/49865/psn-pdf
June 01, 2019 - The patient promptly
received 3 L of intravenous fluid. … The patient remained hypotensive, and a lactate level returned at 3.5 mg/dL. … Although all allergy entries
warrant attention to improve quality and safety, penicillin allergy documentation … quality and safety of care. … Blumenthal, MD, MSc
Assistant Professor of Medicine
Quality and Safety Officer for Allergy
Professor
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psnet.ahrq.gov/node/72798/psn-pdf
March 03, 2021 - technology-related
Health information technology (HIT) has had a profound impact on health care delivery and patient … safety,
but unintended consequences remain a concern. … digital-doctor-hope-hype-and-harm-dawn-medicines-computer-age
https://psnet.ahrq.gov/issue/recent-evidence-health-it-improves-patient-safety-issue-brief
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psnet.ahrq.gov/node/73208/psn-pdf
May 05, 2021 - accuracy-practitioner-estimates-probability-diagnosis-and-after-testing
Overdiagnosis is an emerging safety … overdiagnosis-and-overtreatment-quality-problem-insights-healthcare-improvement-research
https://psnet.ahrq.gov/issue/overkill-avalanche-unnecessary-medical-care-harming-patients-physically-and-financially-what … delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
https://psnet.ahrq.gov/perspective/overuse-patient-safety-problem
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psnet.ahrq.gov/node/837903/psn-pdf
August 24, 2022 - impact-drug-error-reduction-software-preventing-harmful-adverse-drug-events-
england
Smart pump software can improve medication safety … but can also introduce patient safety hazards, such as
alert fatigue. … DERS was
45%, but across one year of implementation, severe harm or death was avoided in up to 110 patients
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psnet.ahrq.gov/node/838245/psn-pdf
January 01, 2023 - novel-study-situational-awareness-among-out-hospital-providers-during-online-clinical
https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety … /psnet.ahrq.gov/issue/situational-awareness-what-it-means-clinicians-its-recognition-and-importance-patient-safety
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psnet.ahrq.gov/issue/safety-still-compromised-computer-weaknesses
September 14, 2016 - Newspaper/Magazine Article
Safety still compromised by computer weaknesses. … Citation Text:
Safety still compromised by computer weaknesses. ISMP Medication Safety Alert! … ISMP Medication Safety Alert! Acute Care Edition. August 25, 2005;10:1-3. … Related Resources From the Same Author(s)
"Use as directed" can cause confusion for both patients … July 17, 2018
What price must we pay for safety?
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psnet.ahrq.gov/issue/hospital-error-oversight-called-lax-state-takes-too-long-investigate-mistakes-patient
May 04, 2015 - January 18, 2006
Hospitals save money, but safety is questioned. … April 1, 2024
Optimizing post-acute care patient safety: a scoping review of multifactorial … April 1, 2024
Perspective
The Media’s Role in Patient Safety … May 13, 2019
Tennessee Center for Patient Safety. … August 14, 2013
With Safety in Mind: Mental Health Services and Patient Safety.
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psnet.ahrq.gov/issue/ismp-survey-shows-provider-text-messaging-often-runs-afoul-patient-safety
May 07, 2018 - Citation Text:
ISMP survey shows provider text messaging often runs afoul of patient safety. … November 30, 2016
Managing hospitalized patients with ambulatory pumps: findings from … May 31, 2017
View More
Related Resources
Patient Safety … Primers
Patient Safety 101
June 15, 2024
Using telehealth … October 25, 2017
Perspective
Telemedicine and Patient Safety
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psnet.ahrq.gov/issue/serious-reportable-events
March 21, 2018 - February 15, 2023
Barriers and facilitators to patient engagement in patient safety from … November 30, 2023
Maryland Hospital Patient Safety Program Annual Report. … July 1, 2020
Betsy Lehman Center for Patient Safety. … June 24, 2019
Organisation Patient Safety Incident Reports. … October 15, 2008
Patient Safety Reporting System.
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psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
October 01, 2015 - Electronic Err
October 1, 2004
Changes in medication safety … indicators in England throughout the covid-19 pandemic using OpenSAFELY: population based, retrospective … February 14, 2011
The JCAHO patient safety event taxonomy: a standardized terminology … June 30, 2011
Reducing health care hazards: lessons from the Commercial Aviation Safety … safety.
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psnet.ahrq.gov/node/43859/psn-pdf
May 28, 2015 - point-prevalence-surgical-checklist-use-europe-relationship-hospital-mortality
The initial evidence supporting the impact of the World Health Organization's surgical safety … study evaluated checklist use in 426 hospitals across 28
European nations, involving more than 45,000 patients … there was striking variation in surgical checklist exposure, with checklists used for 0% to 99.6% of patients … point-prevalence-surgical-checklist-use-europe-relationship-hospital-mortality
https://psnet.ahrq.gov/issue/surgical-safety-checklist-reduce-morbidity-and-mortality-global-population … https://psnet.ahrq.gov/issue/introduction-surgical-safety-checklists-ontario-canada
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/46344/psn-pdf
October 13, 2018 - prescription-opioid-use-misuse-and-use-disorders-us-adults-2015-national-
survey-drug-use-and
Opioid safety … The majority of patients who misused opioids did so
without a prescription, with many patients obtaining … reducing opioid prescribing without providing alternative pain
treatment modalities could be harmful to patients … A recent PSNet perspective discussed the patient safety
aspects of the opioid epidemic. … pain-management-and-opioid-epidemic-balancing-societal-and-individual-benefits-and-risks
https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
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psnet.ahrq.gov/web-mm/new-oral-anticoagulants
July 01, 2011 - Efficacy and safety of novel oral anticoagulants for treatment of acute venous thromboembolism: direct … MedWatch Safety Alert. Pradaxa (dabigatran etexilate mesylate) capsules. … October 19, 2016
Patient Safety Primers
Burnout
September … multi-hospital before–after observational study using a point-prevalence approach with an infusion safety … More
See More About The Topic
Hospitals
Health Care Providers
Quality and Safety
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psnet.ahrq.gov/issue/freedom-speak-review-whistleblowing-nhs
April 24, 2013 - February 26, 2014
Identifying Risks and Monitoring Safety: the Role of Patients and Citizens … Safety. … May 21, 2016
Continuous Improvement of Patient Safety: The Case for Change in the NHS … July 25, 2018
Implementing a Program of Patient Safety in Small Rural Hospitals. … March 16, 2016
Junior doctors' views on reporting concerns about patient safety: a qualitative
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psnet.ahrq.gov/issue/path-safe-and-reliable-healthcare
August 20, 2018 - August 22, 2013
Patient Safety Leadership WalkRounds. … April 25, 2016
A 10-Rights framework for patient care quality and safety. … February 3, 2011
Patient safety in obstetrics and gynecology: an agenda for the future … December 22, 2010
Improving patient safety in hospitals: contributions of high-reliability … September 28, 2010
A comprehensive collaborative patient safety residency curriculum
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psnet.ahrq.gov/issue/safety-incidents-primary-care-office-setting
October 12, 2016 - Patient safety in outpatient settings is a growing concern. … October 12, 2016
Patient safety incidents involving sick children in primary care in … April 1, 2020
Classification of patient-safety incidents in primary care. … September 26, 2018
Nature of blame in patient safety incident reports: mixed methods … December 18, 2017
Patient safety incidents involving sick children in primary care in
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psnet.ahrq.gov/node/37961/psn-pdf
May 05, 2010 - Jt
Comm J Qual Patient Saf. 2008;34(6):318-325. … implementation by hospitals: computerized provider order entry, intensivist coverage of critically ill patients … ,
evidence-based hospital referral for high-risk patients, and adoption of the National Quality Forum's … This study found that hospitals that reported implementing at least one patient safety practice
also … safety practices likely indicates an overall commitment to providing higher-quality care.
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psnet.ahrq.gov/node/47649/psn-pdf
January 09, 2019 - Hematology produced a series of guidelines on prophylaxis for venous
thromboembolism, which can be a patient … safety problem among hospitalized patients. … as the preferred agent when medication
prophylaxis is indicated and screening of all hospitalized patients