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9181. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47186/psn-pdf
      October 24, 2018 - Quality, Value, and Patient Safety in Orthopedic Surgery. October 24, 2018 Azar FM, ed. Orthop Clin North Am. 2018;49(4):A1-A8,389-552. https://psnet.ahrq.gov/issue/quality-value-and-patient-safety-orthopedic-surgery Quality and value have intersecting influence on the safety of health care. Articles in this specia…

9182. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837893/psn-pdf
      August 24, 2022 - Exploring nurses' attitudes, skills, and beliefs of medication safety practices. August 24, 2022 Arkin L, Schuermann A, Penoyer D, et al. Exploring nurses' attitudes, skills, and beliefs of medication safety practices. J Nurs Care Qual. 2022;37(4):319-326. doi:10.1097/ncq.0000000000000635. https://psnet.ahrq.gov/i…

9183. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843321/psn-pdf
      February 01, 2023 - Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. February 1, 2023 ISMP Medication Safety Alert! Acute care edition. January 12, 2023;28(1):1-4. https://psnet.ahrq.gov/issue/latent-and-active-failures-perfectly-align-allow-preventable-adverse-event- reach-patient …

9184. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46079/psn-pdf
      June 28, 2017 - Death due to pharmacy compounding error reinforces need for safety focus. June 28, 2017 ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4. https://psnet.ahrq.gov/issue/death-due-pharmacy-compounding-error-reinforces-need-safety-focus Compounding pharmacies prepare medicines for patients that a…

9185. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73977/psn-pdf
      October 20, 2021 - Optimizing situation awareness to reduce emergency transfers in hospitalized children. October 20, 2021 Sosa T, Sitterding M, Dewan M, et al. Optimizing situation awareness to reduce emergency transfers in hospitalized children. Pediatrics. 2021;148(4):e2020034603. doi:10.1542/peds.2020-034603. https://psnet.ahrq.…

9186. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837510/psn-pdf
      June 22, 2022 - In situ simulation for adoption of new technology to improve sepsis care in rural emergency departments. June 22, 2022 Powell ES, Bond WF, Barker LT, et al. In situ simulation for adoption of new technology to improve sepsis care in rural emergency departments. J Patient Saf. 2022;18(4):302-309. doi:10.1097/pts.00…

9187. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34777/psn-pdf
      February 16, 2011 - Systems errors versus physicians' errors: finding the balance in medical education. February 16, 2011 Casarett D, Helms C. Systems errors versus physicians' errors: finding the balance in medical education. Acad Med. 1999;74(1):19-22. https://psnet.ahrq.gov/issue/systems-errors-versus-physicians-errors-finding-bal…

9188. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73386/psn-pdf
      June 16, 2021 - Healthcare professionals' encounters with ethnic minority patients: the critical incident approach. June 16, 2021 Debesay J, Kartzow AH, Fougner M. Healthcare professionals’ encounters with ethnic minority patients: the critical incident approach. Nurs Inq. 2021;29(1):e12421. doi:10.1111/nin.12421. https://psnet.a…

9189. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46982/psn-pdf
      June 13, 2018 - Advances in perioperative quality and safety. June 13, 2018 Anderson KT, Appelbaum R, Bartz-Kurycki MA, et al. Advances in perioperative quality and safety. Semin Pediatr Surg. 2018;27(2):92-101. doi:10.1053/j.sempedsurg.2018.02.006. https://psnet.ahrq.gov/issue/advances-perioperative-quality-and-safety Clinical s…

9190. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34803/psn-pdf
      January 05, 2017 - Systematic root cause analysis of adverse drug events in a tertiary referral hospital. January 5, 2017 Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary Referral Hospital. Jt Comm J Qual Improv. 2016;26(10). doi:10.1016/s1070-3241(00)26048-3. https://psnet.ah…

9191. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/844774/psn-pdf
      September 11, 2019 - Advances in Human Factors and Ergonomics in Healthcare and Medical Devices. September 11, 2019 Lightner NJ, Kalra J, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030204501. https://psnet.ahrq.gov/issue/advances-human-factors-and-ergonomics-healthcare-and-medical-devices Human-centered processes, techno…

9192. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44737/psn-pdf
      December 16, 2015 - How effective are incident-reporting systems for improving patient safety? A systematic literature review. December 16, 2015 Stavropoulou C, Doherty C, Tosey P. Milbank Q. 2015;93(4):826-866. https://psnet.ahrq.gov/issue/how-effective-are-incident-reporting-systems-improving-patient-safety- systematic-literature …

9193. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867046/psn-pdf
      October 30, 2024 - The future of safety and quality in radiation oncology. October 30, 2024 Talcott W, Covington E, Bazan J, et al. The future of safety and quality in radiation oncology. Semin Radiat Oncol. 2024;34(4):433-440. doi:10.1016/j.semradonc.2024.07.008. https://psnet.ahrq.gov/issue/future-safety-and-quality-radiation-oncol…

9194. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43667/psn-pdf
      November 12, 2014 - Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. November 12, 2014 Hogan H, Healey F, Neale G, et al. Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. J R Soc Med. 2014;107(9):365-75. doi:10.1177/0141076814532394…

9195. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/844768/psn-pdf
      September 11, 2019 - Standardized orders for titrating vasopressors: do efforts to improve safety slow delivery of care? September 11, 2019 Baker DW, Campbell R. Standardized Orders for Titrating Vasopressors: Do Efforts to Improve Safety Slow Delivery of Care? Jt Comm J Qual Patient Saf. 2019;45(9):589-590. doi:10.1016/j.jcjq.2019.07.…

9196. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47747/psn-pdf
      March 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…

9197. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866283/psn-pdf
      July 10, 2024 - Safety and Quality of Parenteral Nutrition: Translating Guidelines into Clinical Practice Considering Different Organizational Settings. July 10, 2024 Am J Health Syst Pharm. 2024;81(supp 3):s73-s136. https://psnet.ahrq.gov/issue/safety-and-quality-parenteral-nutrition-translating-guidelines-clinical-practice- co…

9198. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866698/psn-pdf
      September 11, 2024 - Can we ensure medication safety with the use of speech recognition software? September 11, 2024 Can we ensure medication safety with the use of speech recognition software? ISMP Medication Safety Alert! Acute Care. August 22, 2024;29(17):1-3. https://psnet.ahrq.gov/issue/can-we-ensure-medication-safety-use-speech-…

9199. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45848/psn-pdf
      November 19, 2018 - New Horizons in Patient Safety: Understanding Communication: Case Studies for Physicians. November 19, 2018 Hannawa AF, Wu AW, Juhasz RS, eds. Berlin, Germany: DeGruyter; 2017. ISBN: 9783110455014. https://psnet.ahrq.gov/issue/new-horizons-patient-safety-understanding-communication-case-studies- physicians Poor c…

9200. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43870/psn-pdf
      January 28, 2015 - Peer review of medical practices: missed opportunities to learn. January 28, 2015 Kadar N. Peer review of medical practices: missed opportunities to learn. Am J Obstet Gynecol. 2014;211(6):596-601. doi:10.1016/j.ajog.2014.08.018. https://psnet.ahrq.gov/issue/peer-review-medical-practices-missed-opportunities-learn…