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8941. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39110/psn-pdf
      June 10, 2018 - Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. November 5, 2009;14:1-3. https://psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time- leading-dru…

8942. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47647/psn-pdf
      January 23, 2019 - Patient Safety: Global Action on Patient Safety. January 23, 2019 Executive Board EB144/29 144th session. Geneva, Switzerland: World Health Organization; December 12, 2018. https://psnet.ahrq.gov/issue/patient-safety-global-action-patient-safety This guidance summarizes the current status of global patient safety,…

8943. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43394/psn-pdf
      July 30, 2014 - With oral chemotherapy, we simply must do better! July 30, 2014 ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4. https://psnet.ahrq.gov/issue/oral-chemotherapy-we-simply-must-do-better To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter …

8944. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37276/psn-pdf
      December 23, 2011 - Team management training using crisis resource management results in perceived benefits by healthcare workers. December 23, 2011 Rudy SJ, Polomano R, Murray WB, et al. Team management training using crisis resource management results in perceived benefits by healthcare workers. J Contin Educ Nurs. 2007;38(5):219-2…

8945. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866257/psn-pdf
      July 25, 2024 - Enhancing Surgical Team Communication: SOPS and TeamSTEPPS in Action. July 10, 2024 Agency for Healthcare Research and Quality. July 25, 2024. https://psnet.ahrq.gov/issue/enhancing-surgical-team-communication-sops-and-teamstepps-action Teamwork in the surgical suite is core to safe care but can be challenging to …

8946. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/859351/psn-pdf
      January 01, 2024 - Changing the patient safety mindset: can safety cases help? December 20, 2023 Sujan M, Habli I. Changing the patient safety mindset: can safety cases help? BMJ Qual Saf. 2024;33(3):145-148. doi:10.1136/bmjqs-2023-016652. https://psnet.ahrq.gov/issue/changing-patient-safety-mindset-can-safety-cases-help Examinatio…

8947. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72583/psn-pdf
      December 16, 2020 - Wear face masks with no metal during MRI exams. December 16, 2020 FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 7, 2020. https://psnet.ahrq.gov/issue/wear-face-masks-no-metal-during-mri-exams Magnetic resonance imaging (MRI) requires patient prep…

8948. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43243/psn-pdf
      June 11, 2014 - Improved incident reporting following the implementation of a standardized emergency department peer review process. June 11, 2014 Reznek MA, Barton BA. Improved incident reporting following the implementation of a standardized emergency department peer review process. Int J Qual Health Care. 2014;26(3):278-86. d…

8949. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43458/psn-pdf
      August 27, 2014 - Validation of a teamwork perceptions measure to increase patient safety. August 27, 2014 Keebler JR, Dietz AS, Lazzara EH, et al. Validation of a teamwork perceptions measure to increase patient safety. BMJ Qual Saf. 2014;23(9):718-26. doi:10.1136/bmjqs-2013-001942. https://psnet.ahrq.gov/issue/validation-teamwork…

8950. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34820/psn-pdf
      February 04, 2010 - Waiting for urgent procedures on the weekend among emergently hospitalized patients. February 4, 2010 Bell CM, Redelmeier DA. Waiting for urgent procedures on the weekend among emergently hospitalized patients. Am J Med. 2004;117(3):175-81. https://psnet.ahrq.gov/issue/waiting-urgent-procedures-weekend-among-emerg…

8951. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35724/psn-pdf
      May 26, 2010 - A prospective study of patient safety in the operating room. May 26, 2010 Christian CK, Gustafson ML, Roth EM, et al. A prospective study of patient safety in the operating room. Surgery. 2006;139(2):159-173. https://psnet.ahrq.gov/issue/prospective-study-patient-safety-operating-room This study used a multidisci…

8952. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865721/psn-pdf
      May 01, 2024 - Patient Safety Rights Charter. May 1, 2024 Geneva, Switzerland: World Health Organization; April 2024. ISBN: 9789240093249. https://psnet.ahrq.gov/issue/patient-safety-rights-charter Patients have the right to expect safe, equitable, high-quality care. This 10-point charter serves to describe the establishmen…

8953. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865932/psn-pdf
      May 22, 2024 - Cognitive Load Theory and its Impact on Diagnostic Accuracy. May 22, 2024 Knees M, Raffel KE, Kissler M, et al. Rockville, MD: Agency for Healthcare Research and Quality; May 2024. Publication No. 24-0010-2-EF. https://psnet.ahrq.gov/issue/cognitive-load-theory-and-its-impact-diagnostic-accuracy Cognition plays a…

8954. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46400/psn-pdf
      September 06, 2017 - The Charter on Professionalism for Health Care Organizations. September 6, 2017 Egener BE, Mason DJ, McDonald WJ, et al. The Charter on Professionalism for Health Care Organizations. Acad Med. 2017;92(8):1091-1099. doi:10.1097/ACM.0000000000001561. https://psnet.ahrq.gov/issue/charter-professionalism-health-care-o…

8955. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40556/psn-pdf
      June 29, 2011 - A review of medical error taxonomies: a human factors perspective. June 29, 2011 Taib IA, McIntosh AS, Caponecchia C, et al. A review of medical error taxonomies: A human factors perspective. Saf Sci. 2011;49(5):607-615. doi:10.1016/j.ssci.2010.12.014. https://psnet.ahrq.gov/issue/review-medical-error-taxonomies-h…

8956. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43826/psn-pdf
      June 01, 2015 - Radiation Oncology Incident Learning System. June 1, 2015 American Society for Radiation Oncology and American Association of Physicists in Medicine. https://psnet.ahrq.gov/issue/radiation-oncology-incident-learning-system Reporting of near misses and adverse events can provide a foundation for learning from error.…

8957. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44281/psn-pdf
      July 22, 2015 - Surgeon Scorecard. July 22, 2015 Wei S; Allen M; Pierce O. https://psnet.ahrq.gov/issue/surgeon-scorecard Transparency has been advocated as a key element of safe, patient-centered care, but data on individual performance has not been made widely available. This database compiles the death and complication rates …

8958. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39090/psn-pdf
      November 11, 2009 - Nurse reports of adverse events during sedation procedures at a pediatric hospital. November 11, 2009 Lightdale JR, Mahoney LB, Fredette ME, et al. Nurse reports of adverse events during sedation procedures at a pediatric hospital. J Perianesth Nurs. 2009;24(5):300-6. doi:10.1016/j.jopan.2009.07.004. https://psnet…

8959. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34681/psn-pdf
      February 09, 2011 - No-fault compensation for medical injuries: the prospect for error prevention. February 9, 2011 Studdert DM, Brennan TA. No-Fault Compensation for Medical Injuries. JAMA. 2003;286(2). doi:10.1001/jama.286.2.217. https://psnet.ahrq.gov/issue/no-fault-compensation-medical-injuries-prospect-error-prevention The auth…

8960. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47739/psn-pdf
      February 20, 2019 - Artificial intelligence, bias and clinical safety. February 20, 2019 Challen R, Denny J, Pitt M, et al. Artificial intelligence, bias and clinical safety. BMJ Qual Saf. 2019;28(3):231-237. doi:10.1136/bmjqs-2018-008370. https://psnet.ahrq.gov/issue/artificial-intelligence-bias-and-clinical-safety Artificial intell…