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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73870/psn-pdfSeptember 22, 2021 - Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery. September 22, 2021 Combs CA, Einerson BD, Toner LE. Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery. Am J Obstet Gynecol. 2021;225(5):b43-b49. doi:10.1016… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46825/psn-pdfJune 19, 2018 - Diagnostic performance dashboards: tracking diagnostic errors using big data. June 19, 2018 Mane KK, Rubenstein KB, Nassery N, et al. Diagnostic performance dashboards: tracking diagnostic errors using big data. BMJ Qual Saf. 2018;27(7):567-570. doi:10.1136/bmjqs-2018-007945. https://psnet.ahrq.gov/issue/diagnosti… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837895/psn-pdfAugust 24, 2022 - Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia. August 24, 2022 Keil O, Brunsmann K, Boethig D, et al. Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia. Paediatr Anaesth. 2022;32(10):1144-1150. doi:10.1111/pan.14535.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43368/psn-pdfOctober 01, 2014 - Improving safety and quality of care with enhanced teamwork through operating room briefings. October 1, 2014 Hicks CW, Rosen MA, Hobson DB, et al. Improving safety and quality of care with enhanced teamwork through operating room briefings. JAMA Surg. 2014;149(8):863-8. doi:10.1001/jamasurg.2014.172. https://psne… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45584/psn-pdfNovember 02, 2016 - Discrepancies between prescribed and actual pediatric home parenteral nutrition solutions. November 2, 2016 Raphael BP, Murphy M, Gura KM, et al. Discrepancies Between Prescribed and Actual Pediatric Home Parenteral Nutrition Solutions. Nutr Clin Pract. 2016;31(5):654-658. doi:10.1177/0884533616639410. https://psn… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46815/psn-pdfApril 29, 2018 - Designing and evaluating an automated system for real- time medication administration error detection in a neonatal intensive care unit. April 29, 2018 Ni Y, Lingren T, Hall ES, et al. Designing and evaluating an automated system for real-time medication administration error detection in a neonatal intensive care … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73462/psn-pdfJuly 07, 2021 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries. July 7, 2021 Abela G. Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries. J Tissue Viability. 2021;30(3):339-345. doi:10.1016/j.jtv.2021.04.00… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46054/psn-pdfJanuary 01, 2021 - Misuse of pediatric medications and parent–physician communication: an interactive voice response intervention. April 12, 2017 Walsh KE, Bacic J, Phillips BD, et al. Misuse of Pediatric Medications and Parent-Physician Communication: An Interactive Voice Response Intervention. J Patient Saf. 2021;17(3):e177-e185. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41839/psn-pdfNovember 27, 2012 - A systematic approach to the identification and classification of near-miss events on labor and delivery in a large, national health care system. November 27, 2012 Clark SL, Meyers JA, Frye DR, et al. A systematic approach to the identification and classification of near- miss events on labor and delivery in a lar… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41774/psn-pdfOctober 24, 2012 - Health information technology and its effects on hospital costs, outcomes, and patient safety. October 24, 2012 Encinosa W, Bae J. Health information technology and its effects on hospital costs, outcomes, and patient safety. Inquiry. 2011;48(4):288-303. https://psnet.ahrq.gov/issue/health-information-technology-a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35850/psn-pdfMay 27, 2011 - Computerization can create safety hazards: a bar-coding near miss. May 27, 2011 McDonald CJ. Computerization can create safety hazards: a bar-coding near miss. Ann Intern Med. 2006;144(7):510-6. https://psnet.ahrq.gov/issue/computerization-can-create-safety-hazards-bar-coding-near-miss This case study shares the … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/841770/psn-pdfDecember 21, 2022 - A recent two-fold increase in medical adverse event deaths among US inpatients. December 21, 2022 Oura P, Sajantila A. A recent two-fold increase in medical adverse event deaths among US inpatients. J Public Health Res. 2022;11(4):227990362211399. doi:10.1177/22799036221139935. https://psnet.ahrq.gov/issue/recent-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/48171/psn-pdfAugust 21, 2019 - Reducing drug prescription errors and adverse drug events by application of a probabilistic, machine-learning based clinical decision support system in an inpatient setting. August 21, 2019 Segal G, Segev A, Brom A, et al. Reducing drug prescription errors and adverse drug events by application of a probabilistic… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47747/psn-pdfMarch 13, 2019 - A piece of my mind. Hard times and hard stops. March 13, 2019 Lifflander AL. Hard Times and Hard Stops. JAMA. 2019;321(9):837-838. doi:10.1001/jama.2019.1208. https://psnet.ahrq.gov/issue/piece-my-mind-hard-times-and-hard-stops Implementing new information systems can have unintended consequences on processes. This… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/839831/psn-pdfNovember 09, 2022 - A new category of "never events"-ending harmful hospital policies. November 9, 2022 Chokshi DA, Beckman AL. A new category of "never events"-ending harmful hospital policies. JAMA Health Forum. 2022;3(10):e224703. doi:10.1001/jamahealthforum.2022.4703. https://psnet.ahrq.gov/issue/new-category-never-events-ending-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/48011/psn-pdfMay 29, 2019 - Is it time for safeguards in the adoption of robotic surgery? May 29, 2019 Sheetz KH, Dimick JB. Is It Time for Safeguards in the Adoption of Robotic Surgery? JAMA. 2019;321(20):1971-1972. doi:10.1001/jama.2019.3736. https://psnet.ahrq.gov/issue/it-time-safeguards-adoption-robotic-surgery The FDA recently raised … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47773/psn-pdfApril 17, 2019 - People, systems and safety: resilience and excellence in healthcare practice. April 17, 2019 Smith AF, Plunkett E. People, systems and safety: resilience and excellence in healthcare practice. Anaesthesia. 2019;74(4):508-517. doi:10.1111/anae.14519. https://psnet.ahrq.gov/issue/people-systems-and-safety-resilience… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43283/psn-pdfJune 25, 2014 - Development, implementation, and dissemination of the I- PASS Handoff Curriculum: a multisite educational intervention to improve patient handoffs. June 25, 2014 Starmer AJ, O'Toole JK, Rosenbluth G, et al. Development, implementation, and dissemination of the I- PASS handoff curriculum: A multisite educational in… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836852/psn-pdfApril 06, 2022 - Frequency and nature of communication and handoff failures in medical malpractice claims. April 6, 2022 Humphrey KE, Sundberg M, Milliren CE, et al. Frequency and nature of communication and handoff failures in medical malpractice claims. J Patient Saf. 2022;18(2):130-137. doi:10.1097/pts.0000000000000937. https:… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/849135/psn-pdfMay 17, 2023 - Quality and Safety Considerations in Intensity Modulated Radiation Therapy: An ASTRO Safety White Paper Update. May 17, 2023 Moran JM, Bazan JG, Dawes SL, et al. Quality and Safety Considerations in Intensity Modulated Radiation Therapy: An ASTRO Safety White Paper Update. Pract Radiat Oncol. 2023;13(3):203-216. …
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