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6801. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38975/psn-pdf
      November 14, 2018 - Practical Patient Safety. November 14, 2018 Reynard J, Reynolds J, Stevenson P. Oxford, UK: Oxford University Press; 2009. ISBN: 9780199239931. https://psnet.ahrq.gov/issue/practical-patient-safety This book provides an introduction to key patient safety topics and includes a set of 20 case studies to demonstrate …

6802. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35601/psn-pdf
      June 21, 2010 - Is employee discipline the solution for patient safety? June 21, 2010 Mace KA. Is employee discipline the solution for patient safety? Nurs Manag. 2005;36(12):57-59. https://psnet.ahrq.gov/issue/employee-discipline-solution-patient-safety The author provides suggestions on how to support a blame-free culture and en…

6803. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39848/psn-pdf
      April 16, 2018 - Diagnostic error in acute care. April 16, 2018 PA-PSRS Patient Saf Advis. September 2010;7:76-86.   https://psnet.ahrq.gov/issue/diagnostic-error-acute-care Analyzing reports of diagnostic errors, this article discusses common causes and provides suggestions for physicians and patients to prevent such events. htt…

6804. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40415/psn-pdf
      March 08, 2015 - Driving out errors. March 8, 2015 Weinstock M. Driving out errors,. Hospitals & health networks. 2011;85(4):46-9, 2. https://psnet.ahrq.gov/issue/driving-out-errors This article discusses one hospital system's effort to hardwire safety into daily work by having providers look at each patient as a loved one. https…

6805. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37321/psn-pdf
      February 03, 2011 - MRSA Infections. February 3, 2011 Zeller JL, Burke AE, Glass RM. JAMA patient page. MRSA infections. JAMA. 2007;298(15):1826. https://psnet.ahrq.gov/issue/mrsa-infections This fact sheet defines the methicillin-resistant Staphylococcus aureus (MRSA) bacterium, identifies causes of infection and risk factors, and p…

6806. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33908/psn-pdf
      February 04, 2018 - 20 Tips to Help Prevent Medical Errors. February 4, 2018 Agency for Healthcare Research and Quality; AHRQ. https://psnet.ahrq.gov/issue/20-tips-help-prevent-medical-errors This fact sheet for patients provides recommendations to help them prevent medical errors when taking medications, during a hospital stay, and …

6807. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35075/psn-pdf
      August 24, 2005 - The Patient's Guide to Preventing Medical Errors. August 24, 2005 Bernsten KJ. Westport CT: Praeger; 2004. https://psnet.ahrq.gov/issue/patients-guide-preventing-medical-errors The author provides an introduction to issues affecting safety in health care for a consumer audience. The text is interspersed with relev…

6808. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35892/psn-pdf
      July 23, 2010 - Medical errors: should you apologize? July 23, 2010 Weiss GG. Medical errors. Should you apologize? Medical economics. 2006;83(8):50-4. https://psnet.ahrq.gov/issue/medical-errors-should-you-apologize This article discusses disclosure of adverse events from various perspectives and provides suggestions on apologiz…

6809. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38342/psn-pdf
      September 08, 2022 - Consumermedsafety.org September 8, 2022 Institute for Safe Medication Practices; 5200 Butler Pike, Plymouth Meeting, PA 19462. https://psnet.ahrq.gov/issue/consumermedsafetyorg This redesigned Web site provides information about drug safety alerts and allows consumers to help report and prevent medication errors. …

6810. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36872/psn-pdf
      June 16, 2019 - ISMP medication error report analysis. June 16, 2019 Cohen MR. https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-12 This monthly selection of medication error reports provides examples of problems related to medication misadministration, drug shortages, and the appropriate use of the "five rights"…

6811. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36481/psn-pdf
      December 06, 2006 - Introduction to Trigger Tools for Identifying Adverse Events. December 6, 2006 Institute for Healthcare Improvement; IHI https://psnet.ahrq.gov/issue/introduction-trigger-tools-identifying-adverse-events This Web page provides summaries of and links to the various trigger tools available from the Institute for He…

6812. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37127/psn-pdf
      September 24, 2016 - Noise: a distraction, interruption, and safety hazard. September 24, 2016 Beyea SC. Noise: a distraction, interruption, and safety hazard. AORN J. 2007;86(2):281-5. https://psnet.ahrq.gov/issue/noise-distraction-interruption-and-safety-hazard The author discusses how excessive noise affects the safety of care deliv…

6813. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33959/psn-pdf
      January 17, 2012 - Healthcare Failure Mode and Effect Analysis. January 17, 2012 National Center for Patient Safety. https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis These materials provide an introduction to the purpose of healthcare failure mode and effect analysis (HFMEA), the steps of the HFMEA process, a…

6814. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37248/psn-pdf
      December 15, 2011 - Patient safety and quality in surgery. December 15, 2011 McCafferty MH, Polk HC. Patient safety and quality in surgery. Surg Clin North Am. 2007;87(4):867-81, vii. https://psnet.ahrq.gov/issue/patient-safety-and-quality-surgery This article provides an overview of error in surgical care and summarizes activities an…

6815. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39092/psn-pdf
      November 11, 2009 - Empowered Patient Coalition. November 11, 2009 Email: info@EmpoweredPatientCoalition.org. https://psnet.ahrq.gov/issue/empowered-patient-coalition This group aims to engage the public in health care improvement efforts and personal patient support through education, information, and toolkit dissemination. The Web …

6816. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40591/psn-pdf
      July 06, 2011 - Medical misdiagnoses can have fatal consequences. July 6, 2011 Olsen D. State Journal-Register. June 26, 2011. https://psnet.ahrq.gov/issue/medical-misdiagnoses-can-have-fatal-consequences This newspaper article discusses a case of diagnostic error, explores the complexity of the diagnostic process, and provides t…

6817. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40266/psn-pdf
      November 29, 2012 - One & Only Campaign. November 29, 2012 Centers for Disease Control and Prevention, Safe Injection Practices Coalition. https://psnet.ahrq.gov/issue/one-only-campaign This program raises awareness of safe injection practices and provides materials to engage staff and patients in improvement efforts. https://psnet.…

6818. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33994/psn-pdf
      March 17, 2011 - San Diego Center for Patient Safety. March 17, 2011 https://psnet.ahrq.gov/issue/san-diego-center-patient-safety The San Diego Center for Patient Safety (SDCPS) consists of a multidisciplinary team and an associated research infrastructure. The SDCPS provides for patient safety education and supports the introducti…

6819. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40988/psn-pdf
      August 16, 2016 - Situational Awareness and Patient Safety: A Learning Package. August 16, 2016 Parush A, Campbell C, Hunter A, et al. Ottawa, Ontario: The Royal College of Physicians and Surgeons of Canada; 2011. ISBN: 9781926588100. https://psnet.ahrq.gov/issue/situational-awareness-and-patient-safety-learning-package This publi…

6820. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36689/psn-pdf
      June 14, 2011 - Root cause analysis. June 14, 2011 Stecker MS. Root cause analysis. J Vasc Interv Radiol. 2007;18(1 Pt 1):5-8. https://psnet.ahrq.gov/issue/root-cause-analysis The author provides an introduction to root cause analysis and its application to study and prevent medical error. https://psnet.ahrq.gov/issue/root-cause…