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9061. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41188/psn-pdf
      March 07, 2012 - Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients. March 7, 2012 Nakayama DK, Lester SS, Rich DR, et al. Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients. J Pediatr Surg. 2012;47(1):112-8. …

9062. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43096/psn-pdf
      August 22, 2016 - Rapid learning of adverse medical event disclosure and apology. August 22, 2016 Raemer D, Locke S, Walzer TB, et al. Rapid Learning of Adverse Medical Event Disclosure and Apology. J Patient Saf. 2016;12(3):140-7. doi:10.1097/PTS.0000000000000080. https://psnet.ahrq.gov/issue/rapid-learning-adverse-medical-event-d…

9063. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837038/psn-pdf
      May 04, 2022 - Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS. May 4, 2022 London UK: Patient Safety Learning: 2022. https://psnet.ahrq.gov/issue/mind-implementation-gap-persistence-avoidable-harm-nhs Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financi…

9064. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74703/psn-pdf
      January 26, 2022 - Research to improve diagnosis: time to study the real world. January 26, 2022 Ranji SR, Thomas EJ. Research to improve diagnosis: time to study the real world. BMJ Qual Saf. 2022;31(4):255-258. doi:10.1136/bmjqs-2021-014071. https://psnet.ahrq.gov/issue/research-improve-diagnosis-time-study-real-world Diagnostic …

9065. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37347/psn-pdf
      March 28, 2012 - Recognition and management of potential drug-drug interactions in patients on internal medicine wards. March 28, 2012 Vonbach P, Dubied A, Beer JH, et al. Recognition and management of potential drug-drug interactions in patients on internal medicine wards. Eur J Clin Pharmacol. 2007;63(11):1075-83. https://psnet.…

9066. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60851/psn-pdf
      August 26, 2020 - Situativity: A Family of Social Cognitive Theories for Clinical Reasoning and Error. August 26, 2020 Durning S, Holmboe E, Graber ML, eds. Diagnosis(Berl). 2020;7(3):151-344. https://psnet.ahrq.gov/issue/situativity-family-social-cognitive-theories-clinical-reasoning-and-error Challenges to effective clinical reas…

9067. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39042/psn-pdf
      July 13, 2010 - Global oximetry: an international anaesthesia quality improvement project. July 13, 2010 Walker IA, Merry AF, Wilson IH, et al. Global oximetry: an international anaesthesia quality improvement project. Anaesthesia. 2009;64(10):1051-60. doi:10.1111/j.1365-2044.2009.06067.x. https://psnet.ahrq.gov/issue/global-oxim…

9068. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853630/psn-pdf
      September 20, 2023 - California pharmacies are making millions of mistakes. They’re fighting to keep that secret. September 20, 2023 Peterson M. Los Angeles Times. September 5, 2023. https://psnet.ahrq.gov/issue/california-pharmacies-are-making-millions-mistakes-theyre-fighting-keep-secret Safe practice in community pharmacy is challe…

9069. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854834/psn-pdf
      January 01, 2024 - Bringing the equity lens to patient safety event reporting. October 25, 2023 Gandhi TK, Schulson LB, Thomas AD. Bringing the equity lens to patient safety event reporting. Jt Comm J Qual Patient Saf. 2024;50(1):87-89. doi:10.1016/j.jcjq.2023.09.003. https://psnet.ahrq.gov/issue/bringing-equity-lens-patient-safety-e…

9070. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41648/psn-pdf
      September 30, 2012 - Using an objective structured clinical examination to test adherence to Joint Commission National Patient Safety Goal–associated behaviors. September 30, 2012 Pernar LIM, Shaw T, Pozner CN, et al. Using an Objective Structured Clinical Examination to test adherence to Joint Commission National Patient Safety Goal-…

9071. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46143/psn-pdf
      June 14, 2017 - Report of the Announced Inspection of Medication Safety at the Midland Regional Hospital Tullamore, County Offaly. June 14, 2017 Dublin, Ireland: Health Information and Quality Authority; May 2017. https://psnet.ahrq.gov/issue/report-announced-inspection-medication-safety-midland-regional-hospital- tullamore-coun…

9072. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38942/psn-pdf
      November 25, 2009 - Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward. November 25, 2009 Hamman WR, Beaudin-Seiler BM, Beaubien JM, et al. Using in situ simulation to identify and resolve latent environmental threats to patient safety: case …

9073. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37275/psn-pdf
      December 23, 2011 - Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. December 23, 2011 Nebeker JR, Yarnold PR, Soltysik RC, et al. Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. Med Care. 2007;45(10 Supl 2):S81-8. …

9074. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842774/psn-pdf
      January 18, 2023 - ER doctors misdiagnose patients with unusual symptoms. January 18, 2023 Abelson R. New York Times. December 15, 2022. https://psnet.ahrq.gov/issue/er-doctors-misdiagnose-patients-unusual-symptoms Emergency department safety is challenged by factors such as production pressure, burnout, and overcrowding. This news…

9075. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44900/psn-pdf
      April 22, 2016 - When a surgical colleague makes an error. April 22, 2016 Antiel RM, Blinman TA, Rentea RM, et al. When a Surgical Colleague Makes an Error. Pediatrics. 2016;137(3):e20153828. doi:10.1542/peds.2015-3828. https://psnet.ahrq.gov/issue/when-surgical-colleague-makes-error Physicians have become more comfortable with re…

9076. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838083/psn-pdf
      September 14, 2022 - A pause in pediatrics: implementation of a pediatric diagnostic time-out. September 14, 2022 Yale SC, Cohen SS, Kliegman RM, et al. A pause in pediatrics: implementation of a pediatric diagnostic time-out. Diagnosis (Berl). 2022;9(3):348-351. doi:10.1515/dx-2022-0010. https://psnet.ahrq.gov/issue/pause-pediatrics-…

9077. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837077/psn-pdf
      May 11, 2022 - At US hospitals, a drug mix-up is just a few keystrokes away. May 11, 2022 Kelman B. Kaiser Health News. April 29, 2022. https://psnet.ahrq.gov/issue/us-hospitals-drug-mix-just-few-keystrokes-away Technological solutions harbor unique risks that can result in patient harm. This article shares a response to report…

9078. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41985/psn-pdf
      October 26, 2016 - Legislative Report to the General Assembly: Adverse Event Reporting. October 26, 2016 Pino R, Furniss WH, Mueller L, Olson JC. Hartford, CT: Connecticut Department of Public Health; October 2016. https://psnet.ahrq.gov/issue/legislative-report-general-assembly-adverse-event-reporting This annual publication provi…

9079. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42199/psn-pdf
      June 12, 2013 - Contextual information influences diagnosis accuracy and decision making in simulated emergency medicine emergencies. June 12, 2013 McRobert AP, Causer J, Vassiliadis J, et al. Contextual information influences diagnosis accuracy and decision making in simulated emergency medicine emergencies. BMJ Qual Saf. 2013;2…

9080. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/855105/psn-pdf
      January 01, 2024 - Sentinel Event Alert 68: updated surgical fire prevention for the 21st Century. November 8, 2023 Sentinel Event Alert 68: Updated Surgical Fire Prevention for the 21st Century. Jt Comm J Qual Patient Saf. 2024;50(2):157-160. doi:10.1016/j.jcjq.2023.10.003. https://psnet.ahrq.gov/issue/sentinel-event-alert-68-updat…