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8121. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74043/psn-pdf
      September 18, 2023 - DAISY Award for Extraordinary Nurses in Patient Safety. September 18, 2023 The Daisy Foundation and Institute for Healthcare Improvement. https://psnet.ahrq.gov/issue/daisy-award-extraordinary-nurses-patient-safety Nurses have a fundamental role in safe care delivery by fostering a healthy work environment. This aw…

8122. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50874/psn-pdf
      February 05, 2020 - Checking In on the Checklist. February 5, 2020 Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020. https://psnet.ahrq.gov/issue/checking-checklist Checklists are integrated into error reduction strategies and healthcare team communication efforts worldwide but implementation and impact of the tool varies …

8123. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61052/psn-pdf
      April 01, 2019 - Inadvertent Administration of an Oral Liquid Medicine into a Vein. April 1, 2019 Farnborough, UK; Healthcare Safety Investigation Branch: April 2019. https://psnet.ahrq.gov/issue/inadvertent-administration-oral-liquid-medicine-vein Wrong route medication administration is a never event. This report examined the co…

8124. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865348/psn-pdf
      January 01, 2023 - Learning Health Systems January 1, 2023 Agency for Health Research and Quality. https://psnet.ahrq.gov/issue/learning-health-systems The learning health system model centers on the purposeful, systematic use of internal data and knowledge with external evidence to improve the safety and quality of care. This websi…

8125. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41603/psn-pdf
      August 22, 2012 - Nurse–pharmacist collaboration on medication reconciliation prevents potential harm. August 22, 2012 Feldman LS, Costa LL, Feroli R, et al. Nurse-pharmacist collaboration on medication reconciliation prevents potential harm. J Hosp Med. 2012;7(5):396-401. doi:10.1002/jhm.1921. https://psnet.ahrq.gov/issue/nurse-ph…

8126. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39500/psn-pdf
      January 03, 2017 - Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. January 3, 2017 Lighthall GK, Poon T, Harrison K. Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. Jt Comm J Qual Patient Saf. 2010;36(5):209-16. https://psnet.ahrq.gov/issue/using-situ-simulation-improve-h…

8127. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35411/psn-pdf
      September 27, 2016 - Understanding the cognitive work of nursing in the acute care environment. September 27, 2016 Potter P, Wolf L, Boxerman S, et al. Understanding the cognitive work of nursing in the acute care environment. J Nurs Adm. 2005;35(7-8):327-335. https://journals.lww.com/jonajournal/Abstract/2005/07000/Understanding_the_…

8128. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840494/psn-pdf
      November 30, 2022 - Safety of anesthetic and perioperative medication practices. November 30, 2022 Meyer TA. Anesthesiology News. October 31, 2022. https://psnet.ahrq.gov/issue/safety-anesthetic-and-perioperative-medication-practices Medication use in the surgical environment is complex and high-risk. This article describes steps tow…

8129. 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…

8130. 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.…

8131. 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…

8132. 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…

8133. 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…

8134. 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-…

8135. 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…

8136. 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…

8137. 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…

8138. 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…

8139. 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…

8140. 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…