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6861. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41218/psn-pdf
      March 14, 2012 - Medication errors: when pharmacy is closed. March 14, 2012 PA-PSRS Patient Saf Advis. March 2012;9:11-17. https://psnet.ahrq.gov/issue/medication-errors-when-pharmacy-closed This newsletter article discusses data on medication errors that occurred when pharmacy departments were closed and provides strategies to pr…

6862. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38917/psn-pdf
      September 06, 2013 - Health Care–Associated Infections. September 6, 2013 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/health-care-associated-infections For health care providers and consumers, this Web site features information, tools, and resources on health care–associated infections (HAIs). AHRQ-funded …

6863. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38672/psn-pdf
      July 03, 2013 - Avoiding errors associated with insulin therapy. July 3, 2013 Cohen H. Medscape CME/CE. May 14, 2009. https://psnet.ahrq.gov/issue/avoiding-errors-associated-insulin-therapy This CME-accredited educational activity discusses safety concerns surrounding insulin therapy and provides strategies for clinicians to prev…

6864. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37715/psn-pdf
      May 02, 2018 - FDA Advise-ERR: medication errors associated with Cerebyx. May 2, 2018 ISMP Medication Safety Alert! Acute Care Edition. April 10, 2008;13:1-2. https://psnet.ahrq.gov/issue/fda-advise-err-medication-errors-associated-cerebyx This article describes medication errors caused by unclear labeling of the medication Cere…

6865. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73598/psn-pdf
      May 17, 2022 - Patient Safety Article Collection. May 17, 2022 American Patient Rights Association. 2012-2022. https://psnet.ahrq.gov/issue/patient-safety-article-collection This resource collection highlights news items that examine the potential for patients to be put at risk for emotional, financial, or physical harm. https:…

6866. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37341/psn-pdf
      January 20, 2010 - Patient-Centered Care: What Does It Take? January 20, 2010 Shaller D. The Commonwealth Fund. October 2007. https://psnet.ahrq.gov/issue/patient-centered-care-what-does-it-take By sharing the insights of health care leaders, this report identifies important factors for integrating patient- centered care into organi…

6867. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37697/psn-pdf
      June 16, 2019 - ISMP medication error report analysis. June 16, 2019 Cohen MR, Smetzer JL. Hosp Pharm. 2008;43:168-171. https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-23 This monthly selection of medication error reports provides examples of misinterpretation of dose information, mix-ups of look-alike fluid ba…

6868. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37493/psn-pdf
      December 27, 2014 - Patient Safety Through Teamwork and Communication Toolkit. December 27, 2014 Denver Health. https://psnet.ahrq.gov/issue/patient-safety-through-teamwork-and-communication-toolkit Part of the AHRQ-funded PIPS program, this module provides educational materials for health care workers regarding teamwork and communi…

6869. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38810/psn-pdf
      July 22, 2009 - When doctors make mistakes. July 22, 2009 Chen PW. https://psnet.ahrq.gov/issue/when-doctors-make-mistakes-1 This column shares one physician's experience with the deterioration of a colleague's practice after involvement in error. The piece highlights the need for effective support of physicians-in-training to ma…

6870. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36171/psn-pdf
      September 29, 2010 - Quality and safety in the intensive care unit. September 29, 2010 Stockwell DC, Slonim A. Quality and safety in the intensive care unit. J Intensive Care Med. 2006;21(4):199-210. https://psnet.ahrq.gov/issue/quality-and-safety-intensive-care-unit The authors provide background on patient safety in intensive care u…

6871. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37785/psn-pdf
      May 02, 2018 - Considering insulin pens for routine hospital use? Consider this... May 2, 2018 ISMP Medication Safety Alert! Acute Care Edition. May 8, 2008;13:1-3. https://psnet.ahrq.gov/issue/considering-insulin-pens-routine-hospital-use-consider This article describes common problems associated with insulin pen injectors and …

6872. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39415/psn-pdf
      March 31, 2010 - ISMP's Guidelines for Standard Order Sets. March 31, 2010 Horsham, PA: Institute for Safe Medication Practices; March 2010. https://psnet.ahrq.gov/issue/ismps-guidelines-standard-order-sets To ensure the safety and effectiveness of standard order sets, this guide provides recommendations on content, design, approv…

6873. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34047/psn-pdf
      February 18, 2011 - Improving safety with information technology. February 18, 2011 Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. 2003;348(25):2526- 34. https://psnet.ahrq.gov/issue/improving-safety-information-technology The authors provide a broad overview of the goals, approaches, and limitation…

6874. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36666/psn-pdf
      May 08, 2018 - Heed this warning! Don't miss important computer alerts. May 8, 2018 ISMP Medication Safety Alert! Acute Care Edition. February 8, 2007;12:1-2. https://psnet.ahrq.gov/issue/heed-warning-dont-miss-important-computer-alerts This article discusses the problems associated with bypassing computer alerts and provides re…

6875. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40042/psn-pdf
      June 09, 2015 - AHRQ 2010 Annual Conference. June 9, 2015 Agency for Healthcare Research and Quality; AHRQ. https://psnet.ahrq.gov/issue/ahrq-2010-annual-conference This Web site provides videos of plenary addresses from the 2010 AHRQ Annual Conference, including presentations by Carolyn Clancy, MD, and Atul Gawande, MD. https:/…

6876. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36923/psn-pdf
      June 16, 2019 - ISMP medication error report analysis. June 16, 2019 Cohen MR; Smetzer JL. https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-13 This monthly commentary on medication error discusses the effective use of computer alerts, provides examples of problems related to look-alike injection vials, and share…

6877. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35388/psn-pdf
      February 24, 2011 - Preventing communication errors in telephone medicine. February 24, 2011 Reisman AB, Brown KE. Preventing communication errors in telephone medicine. J Gen Intern Med. 2005;20(10):959-63. https://psnet.ahrq.gov/issue/preventing-communication-errors-telephone-medicine The authors use case scenarios to illustrate po…

6878. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36573/psn-pdf
      June 17, 2014 - Safety First: a Report for Patients, Clinicians and Healthcare Managers. June 17, 2014 National Patient Safety Agency. London, UK: Crown Publishing; 2006. https://psnet.ahrq.gov/issue/safety-first-report-patients-clinicians-and-healthcare-managers This report reviews the challenges of patient safety efforts of the…

6879. A Lot of Pain (Medications) | PSNet
      psnet.ahrq.gov/web-mm/lot-pain-medications
      September 23, 2020 - SPOTLIGHT CASE A Lot of Pain (Medications) Citation Text: Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…

6880. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72614/psn-pdf
      March 01, 2021 - Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes Originally published on December 22, 2020 Last updated on December 23, 2020 https://psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads- improved-outcomes Summary Multidisciplinary tea…