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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44263/psn-pdfNovember 06, 2015 - Delivering the right diet to the right patient every time. November 6, 2015 Wallace SC. PA-PSRS Patient Saf Advis. 2015;12:62-70. https://psnet.ahrq.gov/issue/delivering-right-diet-right-patient-every-time This article analyzed data on dietary errors submitted to a state reporting program and found that more than … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43654/psn-pdfApril 02, 2015 - Nursing bedside clinical handover—an integrated review of issues and tools. April 2, 2015 Anderson J, Malone L, Shanahan K, et al. Nursing bedside clinical handover - an integrated review of issues and tools. J Clin Nurs. 2015;24(5-6):662-671. doi:10.1111/jocn.12706. https://psnet.ahrq.gov/issue/nursing-bedside-cl… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46937/psn-pdfMarch 14, 2018 - Resident shift handoff strategies in US internal medicine residency programs. March 14, 2018 Wray CM, Chaudhry S, Pincavage A, et al. Resident Shift Handoff Strategies in US Internal Medicine Residency Programs. JAMA. 2016;316(21):2273-2275. doi:10.1001/jama.2016.17786. https://psnet.ahrq.gov/issue/resident-shift-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/48142/psn-pdfAugust 21, 2019 - Six ways to lower errors—and unnecessary surgeries—in radiology exams. August 21, 2019 Panner M. Forbes. August 12, 2019. https://psnet.ahrq.gov/issue/six-ways-lower-errors-and-unnecessary-surgeries-radiology-exams Diagnostic errors can result in harm across the spectrum of practice. Discussing cognitive and syste… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38055/psn-pdfJanuary 12, 2009 - Improving patient safety: patient-focused, high-reliability team training. January 12, 2009 McKeon LM, Cunningham PD, Oswaks JSD. Improving patient safety: patient-focused, high-reliability team training. J Nurs Care Qual. 2009;24(1):76-82. doi:10.1097/NCQ.0b013e31818f5595. https://psnet.ahrq.gov/issue/improving-p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41426/psn-pdfJune 06, 2012 - Nursing mortality and morbidity and journal club cycles: paving the way for nursing autonomy, patient safety, and evidence-based practice. June 6, 2012 Staveski S, Leong K, Graham K, et al. Nursing Mortality and Morbidity and Journal Club Cycles. AACN Adv Crit Care. 2012;23(2):133-141. doi:10.1097/nci.0b013e318242… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38488/psn-pdfMarch 18, 2009 - Intensive care units, communication between nurses and physicians, and patients' outcomes. March 18, 2009 Manojlovich M, Antonakos CL, Ronis DL. Intensive care units, communication between nurses and physicians, and patients' outcomes. Am J Crit Care. 2009;18(1):21-30. doi:10.4037/ajcc2009353. https://psnet.ahrq.g… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73354/psn-pdfJune 02, 2021 - Advancing Maternal Health Equity and Reducing Maternal Mortality Workshop. June 2, 2021 National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021. https://psnet.ahrq.gov/issue/advancing-maternal-health-equity-and-reducing-maternal-mortality-workshop Maternal safety is challenged by clinical, equity… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837907/psn-pdfAugust 24, 2022 - ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings. August 24, 2022 Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022. https://psnet.ahrq.gov/issue/ismp-guidelines-safe-medication-use-perioperative-and-procedural-settings Medication errors associated with surgery and… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44909/psn-pdfMarch 23, 2016 - Root Cause Analysis Workbook for Community/Ambulatory Pharmacy. March 23, 2016 Horsham, PA: Institute for Safe Medication Practices; 2013. https://psnet.ahrq.gov/issue/root-cause-analysis-workbook-communityambulatory-pharmacy Root cause analysis offers a structured way to detect and address system weaknesses. This… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43541/psn-pdfAugust 28, 2017 - A step toward high reliability: implementation of a daily safety brief in a children's hospital. August 28, 2017 Saysana M, McCaskey M, Cox E, et al. A Step Toward High Reliability: Implementation of a Daily Safety Brief in a Children's Hospital. J Patient Saf. 2017;13(3):149-152. doi:10.1097/PTS.0000000000000131. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43659/psn-pdfNovember 05, 2014 - Intraoperative patient information handover between anesthesia providers. November 5, 2014 Choromanski D, Frederick J, McKelvey GM, et al. Intraoperative patient information handover between anesthesia providers. J Biomed Res. 2014;28(5):383-387. doi:10.7555/JBR.28.20140001. https://psnet.ahrq.gov/issue/intraopera… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45607/psn-pdfJuly 14, 2019 - Duke Center for Healthcare Safety and Quality. July 14, 2019 Duke University Health System. https://psnet.ahrq.gov/issue/duke-center-healthcare-safety-and-quality This website provides resources to help individuals, hospitals, outpatient practices, and others improve quality and patient safety. The materials inclu… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35186/psn-pdfJuly 13, 2005 - Saving lives: hospitals have signed on to a six-part plan to avoid a multitude of unnecessary deaths. July 13, 2005 Comarow A. US News & World Report. July 2005 https://psnet.ahrq.gov/issue/saving-lives-hospitals-have-signed-six-part-plan-avoid-multitude-unnecessary- deaths This article, accompanying the widely r… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43018/psn-pdfMarch 19, 2014 - Improved obstetric safety through programmatic collaboration. March 19, 2014 Goffman D, Brodman M, Friedman AJ, et al. Improved obstetric safety through programmatic collaboration. J Healthc Risk Manag. 2014;33(3):14-22. doi:10.1002/jhrm.21131. https://psnet.ahrq.gov/issue/improved-obstetric-safety-through-program… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47647/psn-pdfJanuary 23, 2019 - Patient Safety: Global Action on Patient Safety. January 23, 2019 Executive Board EB144/29 144th session. Geneva, Switzerland: World Health Organization; December 12, 2018. https://psnet.ahrq.gov/issue/patient-safety-global-action-patient-safety This guidance summarizes the current status of global patient safety,… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36132/psn-pdfMay 27, 2011 - Motion study in surgery. May 27, 2011 Gilbreth FB. Can J Med Surg. 1916:22-31. https://psnet.ahrq.gov/issue/motion-study-surgery This study was one of the first "time-motion" studies of physicians, and pioneered the application of human factors engineering and industrial principles to medical practice. The authors… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46810/psn-pdfApril 18, 2018 - Unintended doses in radiotherapy—over, under and outside? April 18, 2018 Eaton DJ, Byrne JP, Cosgrove VP, et al. Unintended doses in radiotherapy-over, under and outside? Br J Radiol. 2018;91(1084):20170863. doi:10.1259/bjr.20170863. https://psnet.ahrq.gov/issue/unintended-doses-radiotherapy-over-under-and-outside… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38925/psn-pdfSeptember 16, 2009 - A literature review of the individual and systems factors that contribute to medication errors in nursing practice. September 16, 2009 Brady A-M, Malone A-M, Fleming S. A literature review of the individual and systems factors that contribute to medication errors in nursing practice. J Nurs Manag. 2009;17(6):679-97… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/863003/psn-pdfFebruary 21, 2024 - Positive Patient Identification. February 21, 2024 Healthcare Safety Investigation Branch (HSIB), Dorset, UK: Health Services Safety Investigations Body; February 2024. https://psnet.ahrq.gov/issue/positive-patient-identification Patient misidentification can result in medication administration errors, …
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