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8101. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35614/psn-pdf
      March 10, 2011 - Overriding of drug safety alerts in computerized physician order entry. March 10, 2011 van der Sijs H, Aarts J, Vulto A, et al. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc. 2006;13(2):138-47. https://psnet.ahrq.gov/issue/overriding-drug-safety-alerts-computerized-p…

8102. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38136/psn-pdf
      November 21, 2016 - Patients' and family members' experiences of open disclosure following adverse events. November 21, 2016 Iedema R, Sorensen R, Manias E, et al. Patients' and family members' experiences of open disclosure following adverse events. Int J Qual Health Care. 2008;20(6):421-32. doi:10.1093/intqhc/mzn043. https://psnet.…

8103. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45793/psn-pdf
      July 19, 2024 - SHOT Annual Report. July 19, 2024 S Narayan, ed. Manchester, UK: Serious Hazards of Transfusion (SHOT) Steering Group; 2023. ISBN: 9781999596859. https://psnet.ahrq.gov/issue/shot-annual-report-2019 Although errors in the blood transfusion process are rare, they can be harmful. This annual report provides an anal…

8104. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853627/psn-pdf
      September 20, 2023 - Understanding And Addressing Pre-Hospital Diagnostic Delays. September 20, 2023 Health Affairs Forefront; May-September 2023. https://psnet.ahrq.gov/issue/understanding-and-addressing-pre-hospital-diagnostic-delays Diagnostic delays stem from both human and process failures. This series of articles examines how s…

8105. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37359/psn-pdf
      January 02, 2017 - Case study: preventing surgical complications at Baystate Medical Center. January 2, 2017 Fitzgerald J, Kanter G, Benjamin EM. Case Study: Preventing Surgical Complications at Baystate Medical Center. The Joint Commission Journal on Quality and Patient Safety. 2016;33(11). doi:10.1016/s1553- 7250(07)33076-6. http…

8106. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44770/psn-pdf
      September 24, 2016 - Obstacles to research on the effects of interruptions in healthcare. September 24, 2016 Grundgeiger T, Dekker SWA, Sanderson P, et al. Obstacles to research on the effects of interruptions in healthcare. BMJ Qual Saf. 2016;25(6):392-5. doi:10.1136/bmjqs-2015-004083. https://psnet.ahrq.gov/issue/obstacles-research-…

8107. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44678/psn-pdf
      July 05, 2017 - Patient Safety Risk Management Playbook. July 5, 2017 Chicago, IL: American Society for Healthcare Risk Management; 2015. https://psnet.ahrq.gov/issue/patient-safety-risk-management-playbook Proactive risk management is an important component to improving the safety of care. Exploring principles of high reliabilit…

8108. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44880/psn-pdf
      September 06, 2016 - Drug shortages forcing hard decisions on rationing treatments. September 6, 2016 Fink S. New York Times. January 29, 2016. https://psnet.ahrq.gov/issue/drug-shortages-forcing-hard-decisions-rationing-treatments Drug shortages have become a routine challenge in medicine. Reporting on the impact of medication short…

8109. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41989/psn-pdf
      September 27, 2016 - Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety. September 27, 2016 Luther K, Resar RK. Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety. Healthcare executive. 2013;28(1):84-7. https://psnet.ahrq.gov/issue/tapping-front-line…

8110. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35479/psn-pdf
      June 14, 2011 - Implementing root cause analysis in an area health service: views of the participants. June 14, 2011 Middleton S, Walker C, Chester R. Implementing root cause analysis in an area health service: views of the participants. Aust Health Rev. 2005;29(4):422-8. https://psnet.ahrq.gov/issue/implementing-root-cause-analy…

8111. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40004/psn-pdf
      February 01, 2011 - Application of failure mode and effect analysis in a radiology department. February 1, 2011 Thornton E, Brook OR, Mendiratta-Lala M, et al. Application of Failure Mode and Effect Analysis in a Radiology Department. RadioGraphics. 2010;31(1):281-293. doi:10.1148/rg.311105018. https://psnet.ahrq.gov/issue/applicatio…

8112. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36863/psn-pdf
      August 29, 2011 - Embedding quality improvement and patient safety at Liverpool Women's NHS Foundation Trust. August 29, 2011 Scholefield H. Embedding quality improvement and patient safety at Liverpool Women's NHS Foundation Trust. Best Pract Res Clin Obstet Gynaecol. 2007;21(4):593-607. https://psnet.ahrq.gov/issue/embedding-qual…

8113. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38607/psn-pdf
      January 02, 2017 - Pharmacists' medication reconciliation-related clinical interventions in a children's hospital. January 2, 2017 Gardner B, Graner K. Pharmacists' medication reconciliation-related clinical interventions in a children's hospital. Jt Comm J Qual Patient Saf. 2009;35(5):278-82. https://psnet.ahrq.gov/issue/pharmacist…

8114. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865820/psn-pdf
      May 08, 2024 - Breaking the silence on medical mistakes. May 8, 2024 Scott M. The Pulse. New York Public Radio; April 26, 2024. https://psnet.ahrq.gov/issue/breaking-silence-medical-mistakes Individuals involved in medical errors need time and support to process the incident and its consequences. This moderated podcast examines …

8115. Improving Care Transitions of Older Adults | PSNet
      psnet.ahrq.gov/training-catalog/improving-care-transitions-older-adults
      Improving Care Transitions of Older Adults Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization RCTCLEARN.NET Event Description: This program focu…

8116. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60264/psn-pdf
      January 14, 2021 - COVID-19 Content. ISMP Medication Safety Alert! January 14, 2021 March 2020--January 2021. https://psnet.ahrq.gov/issue/special-editions-covid-19-ismp-medication-safety-alert Medication safety is improved through the sharing of frontline improvement experiences and concerns. These articles share recommendations to…

8117. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36564/psn-pdf
      January 12, 2011 - Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010. January 12, 2011 Crane J, Crane FG. Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010. Hosp Top. 2006;84(4):3-8. http…

8118. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39558/psn-pdf
      May 26, 2010 - ReCASTing the RCA: an improved model for performing root cause analyses. May 26, 2010 Pham JC, Kim GR, Natterman JP, et al. ReCASTing the RCA: An Improved Model for Performing Root Cause Analyses. American Journal of Medical Quality. 2010;25(3). doi:10.1177/1062860609359533. https://psnet.ahrq.gov/issue/recasting-…

8119. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60829/psn-pdf
      August 19, 2020 - Patient Safety. August 19, 2020 Levett-Jones T, ed. Clin Sim Nurs. 2020;44(1):1-78; 2020;45(1):1-60. https://psnet.ahrq.gov/issue/patient-safety-20 Simulation is a recognized technique to educate and plan to improve care processes and safety. This pair of special issues highlights the use of simulation in nur…

8120. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45093/psn-pdf
      September 04, 2016 - Radically redesigning patient safety. September 4, 2016 Radick LE. Radically Redesigning Patient Safety. Healthcare executive. 2016;31(2):32-4, 36-40, 42. https://psnet.ahrq.gov/issue/radically-redesigning-patient-safety Leadership and staff commitment are required to achieve improvements in patient safety. Discuss…