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4481. Total Parenteral Nutrition, Multifarious Errors | PSNet
      psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
      January 23, 2017 - Hospitals Health Care Providers Quality and Safety Professionals Internal Medicine Pediatrics

4482. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49742/psn-pdf
      September 01, 2015 - A Fumbled Handoff to Inpatient Rehab September 1, 2015 Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab The Case An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…

4483. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43596/psn-pdf
      December 19, 2014 - The role of the anesthesiologist in perioperative patient safety. December 19, 2014 Wacker J, Staender S. The role of the anesthesiologist in perioperative patient safety. Curr Opin Anaesthesiol. 2014;27(6):649-656. doi:10.1097/ACO.0000000000000124. https://psnet.ahrq.gov/issue/role-anesthesiologist-perioperative-…

4484. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40530/psn-pdf
      September 25, 2011 - Patient safety factors in children dying in a paediatric intensive care unit (PICU): a case notes review study. September 25, 2011 Monroe K, Wang D, Vincent CA, et al. Patient safety factors in children dying in a paediatric intensive care unit (PICU): a case notes review study. BMJ Qual Saf. 2011;20(10):863-8. do…

4485. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38804/psn-pdf
      July 22, 2009 - Tenfold therapeutic dosing errors in young children reported to US poison control centers. July 22, 2009 Crouch BI, Caravati M, Moltz E. Tenfold therapeutic dosing errors in young children reported to U.S. poison control centers. Am J Health Syst Pharm. 2009;66(14):1292-6. doi:10.2146/080377. https://psnet.ahrq.go…

4486. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45281/psn-pdf
      September 01, 2016 - Screen flashes and pop-up reminders: 'alert fatigue' spreads through medicine. September 1, 2016 Luthra S. Kaiser Health News. June 15, 2016. https://psnet.ahrq.gov/issue/screen-flashes-and-pop-reminders-alert-fatigue-spreads-through-medicine Alert fatigue is known to contribute to medical error. This news article…

4487. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38777/psn-pdf
      March 04, 2011 - Perceptions of standards-based electronic prescribing systems as implemented in outpatient primary care: a physician survey. March 4, 2011 Wang J, Patel MH, Schueth AJ, et al. Perceptions of standards-based electronic prescribing systems as implemented in outpatient primary care: a physician survey. J Am Med Infor…

4488. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43284/psn-pdf
      November 28, 2016 - Parental involvement in the preoperative surgical safety checklist is welcomed by both parents and staff. November 28, 2016 Corbally MT, Tierney E. Parental involvement in the preoperative surgical safety checklist is welcomed by both parents and staff. Int J Pediatr. 2014;2014:791490. doi:10.1155/2014/791490. htt…

4489. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853058/psn-pdf
      August 30, 2023 - Diagnostic reliability in teledermatology: a systematic review and a meta-analysis. August 30, 2023 Bourkas AN, Barone N, Bourkas MEC, et al. Diagnostic reliability in teledermatology: a systematic review and a meta-analysis. BMJ Open. 2023;13(8):e068207. doi:10.1136/bmjopen-2022-068207. https://psnet.ahrq.gov/iss…

4490. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46909/psn-pdf
      August 01, 2018 - Guidance on Safe Medical Staffing: Report of a Working Party. August 1, 2018 London, UK: Royal College of Physicians; 2018. ISBN: 9781860167270. https://psnet.ahrq.gov/issue/guidance-safe-medical-staffing-report-working-party Lack of appropriate staffing can diminish the safety and effectiveness of medical service…

4491. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44989/psn-pdf
      July 01, 2016 - Can medical record reviewers reliably identify errors and adverse events in the ED? July 1, 2016 Klasco RS, Wolfe RE, Lee T, et al. Can medical record reviewers reliably identify errors and adverse events in the ED? Am J Emerg Med. 2016;34(6):1043-8. doi:10.1016/j.ajem.2016.03.001. https://psnet.ahrq.gov/issue/can…

4492. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47122/psn-pdf
      June 13, 2018 - Intravenous chemotherapy compounding errors in a follow-up pan-Canadian observational study. June 13, 2018 Gilbert RE, Kozak MC, Dobish RB, et al. Intravenous Chemotherapy Compounding Errors in a Follow-Up Pan-Canadian Observational Study. J Oncol Pract. 2018;14(5):e295-e303. doi:10.1200/JOP.17.00007. https://psne…

4493. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44407/psn-pdf
      April 15, 2016 - Frequency and severity of parenteral nutrition medication errors at a large children's hospital after implementation of electronic ordering and compounding. April 15, 2016 MacKay M, Anderson C, Boehme S, et al. Frequency and Severity of Parenteral Nutrition Medication Errors at a Large Children's Hospital After Im…

4494. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74185/psn-pdf
      January 01, 2022 - The aspects of healthcare quality that are important to health professionals and patients: a qualitative study. December 15, 2021 Hannawa AF, Wu AW, Kolyada A, et al. The aspects of healthcare quality that are important to health professionals and patients: a qualitative study. Patient Educ Couns. 2022;105(6):1561-…

4495. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43030/psn-pdf
      March 26, 2014 - Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors. March 26, 2014 ISMP Medication Safety Alert! Acute care edition. March 13, 2014;19:1-2,4-5.   https://psnet.ahrq.gov/issue/recommendations-practitioners-and-manufacturers-address-system-based- causes-vaccine-…

4496. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866318/psn-pdf
      July 17, 2024 - Methods to increase reliability in quality improvement projects. July 17, 2024 Lenk MA, LaMantia S, Oehler J, et al. Methods to increase reliability in quality improvement projects. Hosp Pediatr. 2024;14(8):e372-e377. doi:10.1542/hpeds.2023-007340. https://psnet.ahrq.gov/issue/methods-increase-reliability-quality-…

4497. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44888/psn-pdf
      April 06, 2016 - Transforming the morbidity and mortality conference to promote safety and quality in a PICU. April 6, 2016 Cifra CL, Bembea MM, Fackler JC, et al. Transforming the morbidity and mortality conference to promote safety and quality in a PICU. Crit Care Med. 2016;17(1):58-66. doi:10.1097/PCC.0000000000000539. https://…

4498. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34730/psn-pdf
      October 29, 2013 - Medication Errors. 2nd ed. October 29, 2013 Cohen MR, ed. Washington DC: American Pharmacists Association; 2007. https://psnet.ahrq.gov/issue/medication-errors-2nd-ed Cohen, executive director of the Institute for Safe Medication Practices (ISMP), combined 25 years of experience as a leader in medication safety wi…

4499. 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…

4500. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45717/psn-pdf
      July 21, 2017 - What have we learnt after 15 years of research into the 'weekend effect'? July 21, 2017 Bray BD, Steventon A. What have we learnt after 15 years of research into the 'weekend effect'? BMJ Qual Saf. 2017;26(8):607-610. doi:10.1136/bmjqs-2016-005793. https://psnet.ahrq.gov/issue/what-have-we-learnt-after-15-years-re…