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9421. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74048/psn-pdf
      November 10, 2021 - Causes of use errors in ventilation devices--systematic review. November 10, 2021 Coldewey B, Diruf A, Röhrig R, et al. Causes of use errors in ventilation devices - systematic review. Appl Ergon. 2021;98:103544. doi:10.1016/j.apergo.2021.103544. https://psnet.ahrq.gov/issue/causes-use-errors-ventilation-devices-s…

9422. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74765/psn-pdf
      February 09, 2022 - Whose responsibility is it to address bullying in health care? February 9, 2022 Whose responsibility is it to address bullying in health care? AMA J Ethics. 2022;23(12):E931-936. doi:10.1001/amajethics.2021.931. https://psnet.ahrq.gov/issue/whose-responsibility-it-address-bullying-health-care Disrespectful behavi…

9423. 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…

9424. 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-…

9425. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46160/psn-pdf
      June 07, 2017 - ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults. June 7, 2017 Horsham, PA: Institute for Safe Medication Practices; May 2017. https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-subcutaneous-insulin-use-adults Insulin is a widely used medication that can contribute to serious patien…

9426. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72535/psn-pdf
      December 02, 2020 - Learning from influenza vaccine errors to prepare for COVID-19 vaccination campaigns. December 2, 2020 ISMP Medication Safety Alert! Acute care edition. November 19, 2020;25(23):1-6. https://psnet.ahrq.gov/issue/learning-influenza-vaccine-errors-prepare-covid-19-vaccination-campaigns Safety professionals enco…

9427. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74215/psn-pdf
      October 25, 2011 - Race and the clinical diagnosis of depression in new primary care patients. October 25, 2011 Lukachko A, Olfson M. Race and the clinical diagnosis of depression in new primary care patients. Gen Hosp Psychiatry. 2011;34(1):98-100. doi:10.1016/j.genhosppsych.2011.09.008. https://psnet.ahrq.gov/issue/race-and-clinic…

9428. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40883/psn-pdf
      February 10, 2012 - Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology. February 10, 2012 Nakhleh RE, Myers JL, Allen TC, et al. Conse…

9429. 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 …

9430. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35672/psn-pdf
      June 28, 2010 - How many hospital pharmacy medication dispensing errors go undetected? June 28, 2010 Cina J, Gandhi TK, Churchill WW, et al. How many hospital pharmacy medication dispensing errors go undetected? Jt Comm J Qual Patient Saf. 2006;32(2):73-80. https://psnet.ahrq.gov/issue/how-many-hospital-pharmacy-medication-dispen…

9431. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61003/psn-pdf
      October 07, 2020 - Making Complaints Count: Supporting Complaints Handling in the NHS and UK Government Departments. October 7, 2020 Manchester, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN 9781528620666. https://psnet.ahrq.gov/issue/making-complaints-count-supporting-complaints-handling-nhs-and-uk- gover…

9432. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838194/psn-pdf
      September 28, 2022 - Measure Dx: implementing pathways to discover and learn from diagnostic errors. September 28, 2022 Bradford A, Shofer M, Singh H. Measure Dx: Implementing pathways to discover and learn from diagnostic errors. Int J Qual Health Care. 2022;34(3):mzac068. doi:10.1093/intqhc/mzac068. https://psnet.ahrq.gov/issue/meas…

9433. 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. …

9434. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45011/psn-pdf
      May 25, 2016 - High Reliability Organizations: A Healthcare Handbook for Patient Safety & Quality. May 25, 2016 Oster C, Braaten J, eds. Indianapolis, IN: Sigma Theta Tau International; 2016. ISBN: 9781940446387. https://psnet.ahrq.gov/issue/high-reliability-organizations-healthcare-handbook-patient-safety-quality This publicati…

9435. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41440/psn-pdf
      August 17, 2016 - The Toolkit for Using the AHRQ Quality Indicators: How To Improve Hospital Quality and Safety. August 17, 2016 Rockville, MD: Agency for Healthcare Research and Quality; July 2016. https://psnet.ahrq.gov/issue/toolkit-using-ahrq-quality-indicators-how-improve-hospital-quality-and-safety This toolkit provides resou…

9436. 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…

9437. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38062/psn-pdf
      March 04, 2011 - Steering patients to safer hospitals? The effect of a tiered hospital network on hospital admissions. March 4, 2011 Scanlon D, Lindrooth R, Christianson JB. Steering patients to safer hospitals? The effect of a tiered hospital network on hospital admissions. Health Serv Res. 2008;43(5 Pt 2):1849-68. doi:10.1111/j.1…

9438. 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…

9439. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49464/psn-pdf
      December 27, 2020 - Lap Burn October 1, 2004 Ball K. Lap Burn. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lap-burn The Case A woman was scheduled for an elective diagnostic laparoscopy for dysfunctional uterine bleeding. After accessing the abdomen with the trocar without complication, the surgeon inserted the laparoscope…

9440. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49652/psn-pdf
      May 01, 2012 - Double Dose at Transfer May 1, 2012 Hackman JL. Double Dose at Transfer. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/double-dose-transfer The Case A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department (ED) for left lower extremity pain, swelling, and erythe…