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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47855/psn-pdf
    June 19, 2019 - Medication Overload: America's Other Drug Problem. June 19, 2019 Brownlee S; Garber J. Brookline, MA: Lown Institute; 2019. https://psnet.ahrq.gov/issue/medication-overload-americas-other-drug-problem Overprescribing is a common problem that contributes to patient harm. This report examines financial, clinical, an…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38326/psn-pdf
    January 14, 2009 - Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting. January 14, 2009 Clay BJ, Halasyamani L, Stucky ER, et al. Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting. J Hosp Med. 2008;3(6). doi:10.1002/jhm.370.…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40070/psn-pdf
    December 08, 2010 - Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine. December 8, 2010 Thyen AB, McAllister RK, Councilman LM. Epidural Pump Programming Error Leading to Inadvertent 10- Fold Dosing Error During Epidural Labor Analgesia With Ropivacaine. J Pat…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45547/psn-pdf
    October 05, 2016 - Sick children face potentially deadly danger: medication errors. October 5, 2016 Furfaro H. Wall Street Journal. September 25, 2016. https://psnet.ahrq.gov/issue/sick-children-face-potentially-deadly-danger-medication-errors Medication errors in pediatric care are common in the hospital and at home. This newspaper…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44074/psn-pdf
    November 16, 2015 - Investigating Clinical Incidents in the NHS. November 16, 2015 Sixth Report of Session 2014–15. House of Commons Public Administration Select Committee. London, England: The Stationery Office; March 27, 2015. Publication HC 886. https://psnet.ahrq.gov/issue/investigating-clinical-incidents-nhs Applying evidence ge…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42844/psn-pdf
    May 29, 2014 - Does the concept of safety culture help or hinder systems thinking in safety? May 29, 2014 Reiman T, Rollenhagen C. Does the concept of safety culture help or hinder systems thinking in safety? Accid Anal Prev. 2014;68(July):5-15. doi:10.1016/j.aap.2013.10.033. https://psnet.ahrq.gov/issue/does-concept-safety-cult…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45557/psn-pdf
    October 27, 2016 - Time-out: the professional and organizational ethics of speaking up in the OR. October 27, 2016 Berlinger N, Dietz E. Time-out: The Professional and Organizational Ethics of Speaking Up in the OR. AMA J Ethics. 2016;18(9):925-32. doi:10.1001/journalofethics.2016.18.9.stas1-1609. https://psnet.ahrq.gov/issue/time-o…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46106/psn-pdf
    August 15, 2018 - Assumptions of quality medicine: the role of uncertainty. August 15, 2018 Scott-Wittenborn N, Schneider JS. Assumptions of Quality Medicine: The Role of Uncertainty. JAMA Otolaryngol Head Neck Surg. 2017;143(8):753-754. doi:10.1001/jamaoto.2017.0257. https://psnet.ahrq.gov/issue/assumptions-quality-medicine-role-un…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44389/psn-pdf
    August 19, 2015 - A method of addressing proprietary name similarity for US prescription drugs. August 19, 2015 Stockbridge MD, Taylor K. A Method of Addressing Proprietary Name Similarity for US Prescription Drugs. Ther Innov Regul Sci. 2015;49(4). doi:10.1177/2168479015570331. https://psnet.ahrq.gov/issue/method-addressing-propri…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40085/psn-pdf
    December 15, 2010 - Medication reconciliation in the emergency department: opportunities for workflow redesign. December 15, 2010 Hummel J, Evans PC, Lee H. Medication reconciliation in the emergency department: opportunities for workflow redesign. Qual Saf Health Care. 2010;19(6):531-5. doi:10.1136/qshc.2009.035121. https://psnet.ah…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40945/psn-pdf
    November 23, 2011 - The nature and causes of unintended events reported at 10 internal medicine departments. November 23, 2011 Lubberding S, Zwaan L, Timmermans D, et al. The nature and causes of unintended events reported at 10 internal medicine departments. J Patient Saf. 2011;7(4):224-31. doi:10.1097/PTS.0b013e3182388f97. https://…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43622/psn-pdf
    December 19, 2014 - Checklist usage decreases critical task omissions when training residents to separate from simulated cardiopulmonary bypass. December 19, 2014 Petrik EW, Ho D, Elahi M, et al. Checklist usage decreases critical task omissions when training residents to separate from simulated cardiopulmonary bypass. J Cardiothorac…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39741/psn-pdf
    October 13, 2010 - Disclosure and reporting of surgical complications: a double-edged sword? October 13, 2010 Stahel PF, Flierl MA, Smith WR, et al. Disclosure and reporting of surgical complications: a double-edged sword? Am J Med Qual. 2010;25(5):398-401. doi:10.1177/1062860610370989. https://psnet.ahrq.gov/issue/disclosure-and-re…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44784/psn-pdf
    May 03, 2017 - WISH Patient Safety Forum May 3, 2017 World Innovation Summit for Health 2015. Doha, Qatar: Qatar Foundation; February 2015. https://psnet.ahrq.gov/issue/wish-patient-safety-forum The 2015 conference focused on persisting barriers to patient safety worldwide and recommended strategies to achieve lasting improvemen…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46602/psn-pdf
    February 21, 2018 - Are quality improvement collaboratives effective? A systematic review. February 21, 2018 Wells S, Tamir O, Gray J, et al. Are quality improvement collaboratives effective? A systematic review. BMJ Qual Saf. 2018;27(3):226-240. doi:10.1136/bmjqs-2017-006926. https://psnet.ahrq.gov/issue/are-quality-improvement-coll…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43302/psn-pdf
    August 21, 2014 - A medication-based trigger tool to identify adverse events in pediatric anesthesiology. August 21, 2014 Taghon T, Elsey N, Miler V, et al. A medication-based trigger tool to identify adverse events in pediatric anesthesiology. Jt Comm J Qual Patient Saf. 2014;40(7):326-334. https://psnet.ahrq.gov/issue/medication-…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44685/psn-pdf
    November 18, 2015 - Root cause analyses of suicides of mental health clients. November 18, 2015 Gillies D, Chicop D, O'Halloran P. Root Cause Analyses of Suicides of Mental Health Clients: Identifying Systematic Processes and Service-Level Prevention Strategies. Crisis. 2015;36(5):316-324. doi:10.1027/0227-5910/a000328. https://psnet…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43888/psn-pdf
    August 02, 2015 - Diagnostic performance by medical students working individually or in teams. August 2, 2015 Hautz WE, Kämmer JE, Schauber SK, et al. Diagnostic performance by medical students working individually or in teams. JAMA. 2015;313(3):303-4. doi:10.1001/jama.2014.15770. https://psnet.ahrq.gov/issue/diagnostic-performance…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45647/psn-pdf
    February 22, 2017 - Bias in the ER. Doctors suffer from the same cognitive distortions as the rest of us. February 22, 2017 Lewis M. Nautilus. February 9, 2017. https://psnet.ahrq.gov/issue/bias-er-doctors-suffer-same-cognitive-distortions-rest-us Physicians' decision-making can be diminished when they are tired, distracted, or too n…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41873/psn-pdf
    November 28, 2012 - A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care. November 28, 2012 Chesluk BJ, Bernabeo E, Hess B, et al. A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care. Health Aff (Millwood). 2012;31(11):2485-2492. do…
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