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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44684/psn-pdfNovember 18, 2015 - Preventing medication errors by empowering patients. November 18, 2015 Karch AM. Am Nurs Today. September 2015;10:18-22. https://psnet.ahrq.gov/issue/preventing-medication-errors-empowering-patients The complexity of care delivery can hinder the role of nurses in preventing medication errors. This commentary advoc… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36263/psn-pdfOctober 21, 2010 - Predictors of treatment error for children with uncomplicated malaria seen as outpatients in Blantyre district, Malawi. October 21, 2010 Osterholt DM, Rowe AK, Hamel MJ, et al. Predictors of treatment error for children with uncomplicated malaria seen as outpatients in Blantyre district, Malawi. Trop Med Int Healt… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35057/psn-pdfFebruary 03, 2011 - Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. February 3, 2011 Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA. 2005;293(21):2609-17. https://psnet.ahrq.gov/issue/defensive… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35079/psn-pdfNovember 04, 2015 - Medical Error: What Do We Know? What Do We Do? November 4, 2015 Rosenthal MM; Sutcliffe KM, eds. San Francisco, CA: Jossey-Bass; 2002. https://psnet.ahrq.gov/issue/medical-error-what-do-we-know-what-do-we-do Opening with a review of lessons learned since the Harvard Medical Practice Study (HMPS), this book explore… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45835/psn-pdfFebruary 01, 2017 - Deploying and measuring a risk and patient safety program. February 1, 2017 Orel H, McGroarty M, Marchegiani H. Deploying and measuring a risk and patient safety program. J Healthc Risk Manag. 2017;36(3):26-33. doi:10.1002/jhrm.21266. https://psnet.ahrq.gov/issue/deploying-and-measuring-risk-and-patient-safety-pro… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35837/psn-pdfMarch 28, 2011 - Building safer systems by ecological design: using restoration science to develop a medication safety intervention. March 28, 2011 Marck PB, Kwan JA, Preville B, et al. Building safer systems by ecological design: using restoration science to develop a medication safety intervention. Qual Saf Health Care. 2006;15(… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/74045/psn-pdfNovember 03, 2021 - ‘They treat me like I’m old and stupid’: seniors decry health providers’ age bias. November 3, 2021 Graham J. Kaiser Health News. October 20, 2021. https://psnet.ahrq.gov/issue/they-treat-me-im-old-and-stupid-seniors-decry-health-providers-age-bias Implicit biases permeate decision making and can impede safe and e… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37375/psn-pdfDecember 05, 2007 - Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. December 5, 2007 Vidyarthi AR, Arora V, Schnipper JL, et al. Managing discontinuity in academic medical centers: Strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1(4). doi:10.1002/jhm.10… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45185/psn-pdfAugust 03, 2016 - Final Report of the Commission on Care. August 3, 2016 Washington, DC: Commission on Care; June 2016. https://psnet.ahrq.gov/issue/final-report-commission-care The Veterans Affairs health system has recently faced challenges associated with access and quality. Providing an assessment of the current and future stat… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/854266/psn-pdfOctober 04, 2023 - Smart Healthcare Safety. October 4, 2023 Plymouth Meeting PA, ECRI. 2019-2023. https://psnet.ahrq.gov/issue/smart-healthcare-safety A wide variety of considerations must converge to inform an understanding of system vulnerabilities and the application of strategies to address them. This series of webinars covers a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43015/psn-pdfMay 29, 2014 - Team-training in healthcare: a narrative synthesis of the literature. May 29, 2014 Weaver SJ, Dy SM, Rosen MA. Team-training in healthcare: a narrative synthesis of the literature. BMJ Qual Saf. 2014;23(5):359-72. doi:10.1136/bmjqs-2013-001848. https://psnet.ahrq.gov/issue/team-training-healthcare-narrative-synthe… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866359/psn-pdfJune 01, 2022 - Diagnostic Safety Toolkit. June 1, 2022 Diagnostic Safety Toolkit. https://psnet.ahrq.gov/issue/diagnostic-safety-toolkit-0 Effective communication is critical as patients shift from one level of care to another as their diagnosis evolves. This toolkit is designed to help academic medical centers initiate conversa… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/856641/psn-pdfJanuary 01, 2009 - WebAIRS Anesthesia Incident Reporting System. January 1, 2009 Australian and New Zealand Tripartite Anaesthetic Data Committee. https://psnet.ahrq.gov/issue/webairs-anesthesia-incident-reporting-system Reporting errors in anesthesiology practice can motivate and inform safety improvement work. This website serves … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47696/psn-pdfFebruary 22, 2019 - Operating room fires. February 22, 2019 Jones TS, Black IH, Robinson TN, et al. Operating Room Fires. Anesthesiology. 2019;130(3):492-501. doi:10.1097/ALN.0000000000002598. https://psnet.ahrq.gov/issue/operating-room-fires Surgical fires, though uncommon, can result in serious harm. This review highlights three co… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38885/psn-pdfAugust 19, 2009 - Patient safety: Part II. Opportunities for improvement in patient safety. August 19, 2009 Elston DM, Stratman E, Johnson-Jahangir H, et al. Patient safety: Part II. Opportunities for improvement in patient safety. J Am Acad Dermatol. 2009;61(2):193-205; quiz 206. doi:10.1016/j.jaad.2009.04.055. https://psnet.ahrq.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47144/psn-pdfJune 13, 2018 - Canadian Anesthesia Incident Reporting System. June 13, 2018 Canadian Anaesthesiologists Society. https://psnet.ahrq.gov/issue/canadian-anesthesia-incident-reporting-system Reporting mistakes in anesthesiology practice can motivate and inform error reduction work. This website provides a secure tool for submitting… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38305/psn-pdfJanuary 15, 2009 - High-alert medications in the pediatric intensive care unit. January 15, 2009 Franke HA, Woods D, Holl JL. High-alert medications in the pediatric intensive care unit. Pediatr Crit Care Med. 2009;10(1):85-90. doi:10.1097/PCC.0b013e3181936ff8. https://psnet.ahrq.gov/issue/high-alert-medications-pediatric-intensive-c… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46557/psn-pdfNovember 22, 2017 - Safe handover. November 22, 2017 Merten H, van Galen LS, Wagner C. Safe handover. BMJ. 2017;359:j4328. doi:10.1136/bmj.j4328. https://psnet.ahrq.gov/issue/safe-handover Patient handovers between clinical teams are a common point of information exchange that can be challenging to perform due to interruptions, produ… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45086/psn-pdfJuly 02, 2019 - Half-life of a printed handoff document. July 2, 2019 Rosenbluth G, Jacolbia R, Milev D, et al. Half-life of a printed handoff document. BMJ Qual Saf. 2016;25(5):324-8. doi:10.1136/bmjqs-2015-004585. https://psnet.ahrq.gov/issue/half-life-printed-handoff-document Despite advances in handoff practices, printed sign… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44502/psn-pdfMay 07, 2018 - Draft Guidelines for the Safe Communication of Electronic Medication Information. May 7, 2018 Institute for Safe Medication Practices. Acute Care Edition. August 27, 2015;2;1-3,6. https://psnet.ahrq.gov/issue/draft-guidelines-safe-communication-electronic-medication-information How electronic medication-related in…
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