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8801. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60719/psn-pdf
      July 22, 2020 - How real-time data can change the patient safety game. July 22, 2020 Diesing G. How real-time data can change the patient safety game. J AHIMA. 2020;July 1. https://psnet.ahrq.gov/issue/how-real-time-data-can-change-patient-safety-game Use of data can improve the response of clinicians to patient concerns and deter…

8802. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46593/psn-pdf
      November 08, 2017 - Unreadable barcodes and multiple barcodes on packages can lead to errors. November 8, 2017 ISMP Medication Safety Alert! Acute care edition. October 19, 2017;22:1-3. https://psnet.ahrq.gov/issue/unreadable-barcodes-and-multiple-barcodes-packages-can-lead-errors Barcodes can both enhance and degrade the medication …

8803. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44468/psn-pdf
      September 23, 2015 - LINNEAUS Collaboration on Patient Safety in Primary Care. September 23, 2015 Eur J Gen Pract. 2015;(suppl 21):1-77. https://psnet.ahrq.gov/issue/linneaus-collaboration-patient-safety-primary-care Collaborative efforts provide learning opportunities for groups that seek to develop widely implementable improvements…

8804. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45659/psn-pdf
      November 16, 2016 - Misdiagnoses: a hidden risk of genetic testing. November 16, 2016 Howard J. CNN. October 31, 2016. https://psnet.ahrq.gov/issue/misdiagnoses-hidden-risk-genetic-testing Although genetic testing can provide proactive assessment for disease, it can also result in unnecessary care. This news article reports on the un…

8805. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42066/psn-pdf
      March 11, 2013 - Stakeholder challenges in purchasing medical devices for patient safety. March 11, 2013 Hinrichs S, Dickerson T, Clarkson J. Stakeholder challenges in purchasing medical devices for patient safety. J Patient Saf. 2013;9(1):36-43. doi:10.1097/PTS.0b013e3182773306. https://psnet.ahrq.gov/issue/stakeholder-challenges…

8806. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47144/psn-pdf
      June 13, 2018 - Canadian Anesthesia Incident Reporting System. June 13, 2018 Canadian Anaesthesiologists Society. https://psnet.ahrq.gov/issue/canadian-anesthesia-incident-reporting-system Reporting mistakes in anesthesiology practice can motivate and inform error reduction work. This website provides a secure tool for submitting…

8807. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46863/psn-pdf
      December 05, 2024 - Safer Together Annual Report. December 5, 2024 Child Health Patient Safety Organization. Washington, DC: Children's Hospital Association. https://psnet.ahrq.gov/issue/perfecting-detection-understanding-source-harm This annual publication provides common cause analyses of incidents submitted to a pediatric patient …

8808. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45086/psn-pdf
      July 02, 2019 - Half-life of a printed handoff document. July 2, 2019 Rosenbluth G, Jacolbia R, Milev D, et al. Half-life of a printed handoff document. BMJ Qual Saf. 2016;25(5):324-8. doi:10.1136/bmjqs-2015-004585. https://psnet.ahrq.gov/issue/half-life-printed-handoff-document Despite advances in handoff practices, printed sign…

8809. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45550/psn-pdf
      August 01, 2023 - Leape Ahead Award. August 1, 2023 American Association for Physician Leadership. https://psnet.ahrq.gov/issue/leape-ahead-award Efforts to incorporate respect and patient safety concepts into medical training have been inspired by the work and leadership of Dr. Lucian Leape, founding chairman of the Lucian Leape I…

8810. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45211/psn-pdf
      October 11, 2016 - Safety in Medication Use. October 11, 2016 Tully MP, Franklin BD, eds. Boca Raton, FL: CRC Press, Taylor and Francis Group; 2016. ISBN: 9781482227000. https://psnet.ahrq.gov/issue/safety-medication-use Errors in the prescription, preparation, and administration of medications hinder safe patient care. This book s…

8811. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35254/psn-pdf
      April 06, 2011 - Adverse events and near miss reporting in the NHS. April 6, 2011 Shaw R. Adverse events and near miss reporting in the NHS. Quality and Safety in Health Care. 2005;14(4). doi:10.1136/qshc.2004.010553. https://psnet.ahrq.gov/issue/adverse-events-and-near-miss-reporting-nhs This study evaluated the utility of a volu…

8812. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44223/psn-pdf
      November 22, 2016 - Patient Safety and Incident Management Toolkit. November 22, 2016 Edmonton, AB: Canadian Patient Safety Institute. June 2015. https://psnet.ahrq.gov/issue/patient-safety-and-incident-management-toolkit Engaging patients and families in safety can uncover concerns and inform improvement efforts. This three- compone…

8813. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44502/psn-pdf
      May 07, 2018 - Draft Guidelines for the Safe Communication of Electronic Medication Information. May 7, 2018 Institute for Safe Medication Practices. Acute Care Edition. August 27, 2015;2;1-3,6. https://psnet.ahrq.gov/issue/draft-guidelines-safe-communication-electronic-medication-information How electronic medication-related in…

8814. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43183/psn-pdf
      May 14, 2014 - Physician: 'I almost killed a patient' because of an advance directive. May 14, 2014 Betbeze P. HealthLeaders Media. May 2, 2014. https://psnet.ahrq.gov/issue/physician-i-almost-killed-patient-because-advance-directive Reporting on how misinterpretation of advance directives and living wills can detract from patie…

8815. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39690/psn-pdf
      July 21, 2010 - Characteristics of quality and patient safety curricula in major teaching hospitals. July 21, 2010 Pingleton SK, Davis DA, Dickler RM. Characteristics of quality and patient safety curricula in major teaching hospitals. Am J Med Qual. 2010;25(4):305-11. doi:10.1177/1062860610367677. https://psnet.ahrq.gov/issue/ch…

8816. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41676/psn-pdf
      September 24, 2016 - Taking a detour: positive and negative effects of supervisors' interruptions during admission case review discussions. September 24, 2016 Goldszmidt M, Aziz N, Lingard LA. Taking a detour: positive and negative effects of supervisors' interruptions during admission case review discussions. Acad Med. 2012;87(10):13…

8817. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39830/psn-pdf
      April 17, 2011 - 2010 Annual National Patient Safety Foundation Congress: conference proceedings. April 17, 2011 Pinakiewicz DC, Bonacum D, Youngberg BJ, et al. 2010 Annual National Patient Safety Foundation Congress: conference proceedings. J Patient Saf. 2010;6(3):128-36. https://psnet.ahrq.gov/issue/2010-annual-national-patient…

8818. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38574/psn-pdf
      November 21, 2016 - Family-identified barriers to medication reconciliation. November 21, 2016 Riley-Lawless K. Family-identified barriers to medication reconciliation. J Spec Pediatr Nurs. 2009;14(2):94-101. doi:10.1111/j.1744-6155.2009.00182.x. https://psnet.ahrq.gov/issue/family-identified-barriers-medication-reconciliation Medica…

8819. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37527/psn-pdf
      August 24, 2015 - MEDMARX Data Report: A Report on the Relationship of Drug Names and Medication Errors in Response to the Institute of Medicine's Call to Action (2003-2006 Findings and Trends 2002-2006). August 24, 2015 Hicks RW, Becker SC, Cousins DD, eds. Rockville, MD: Center for the Advancement of Patient Safety, US Pharmacop…

8820. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44977/psn-pdf
      March 01, 2020 - Choosing a Patient Safety Organization March 1, 2020 Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0030. https://psnet.ahrq.gov/issue/choosing-patient-safety-organization Patient safety organizations (PSOs) collect and analyze protected incident data from across the …