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6901. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43357/psn-pdf
      July 16, 2014 - Wake Up Safe. July 16, 2014 Society for Pediatric Anesthesia. https://psnet.ahrq.gov/issue/wake-safe This Web site provides information about a Patient Safety Organization initiative to develop an adverse event registry in perioperative care for pediatric patients, determine causes for errors, and design preventi…

6902. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37753/psn-pdf
      May 02, 2018 - Some red rules shouldn't rule in hospitals. May 2, 2018 ISMP Medication Safety Alert! Acute Care Edition. April 24, 2008;13:1-3. https://psnet.ahrq.gov/issue/some-red-rules-shouldnt-rule-hospitals This article provides a set of criteria for health care professionals to develop and implement red rules as an effecti…

6903. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35160/psn-pdf
      January 02, 2017 - Unlabeled containers lead to patient's death. January 2, 2017 Cohen MR, Smetzer JL. Unlabeled containers lead to patient's death. Jt Comm J Qual Patient Saf. 2005;31(7):414-7. https://psnet.ahrq.gov/issue/unlabeled-containers-lead-patients-death The authors review selected incidents of harm involving unlabeled con…

6904. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33913/psn-pdf
      December 22, 2014 - HCUPnet. December 22, 2014 Agency for Healthcare Research and Quality https://psnet.ahrq.gov/issue/hcupnet This interactive tool identifies, tracks, analyzes, and compares statistics on hospital care. It is part of the Healthcare Cost and Utilization Project (HCUP). With HCUPnet, users gain easy access to all nati…

6905. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35974/psn-pdf
      May 08, 2018 - Tablet splitting: Do it only if you "half" to, and then do it safely. May 8, 2018 ISMP Medication Safety Alert! Acute Care Edition. May 18, 2006;11:1-2. https://psnet.ahrq.gov/issue/tablet-splitting-do-it-only-if-you-half-and-then-do-it-safely This alert presents the risks involved with tablet splitting and outlin…

6906. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35422/psn-pdf
      June 17, 2014 - Medication safety issue brief. Medication reconciliation. June 17, 2014 Hosp Health Netw. 2005 Sep;79(9):33-34. https://psnet.ahrq.gov/issue/medication-safety-issue-brief-medication-reconciliation This issue brief provides case studies from hospitals that have successfully implemented medication reconciliation pro…

6907. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35746/psn-pdf
      July 15, 2010 - Availability of Spanish prescription labels. July 15, 2010 Sharif I, Lo S, Ozuah PO. Availability of Spanish prescription labels. J Health Care Poor Underserved. 2006;17(1):65-9. https://psnet.ahrq.gov/issue/availability-spanish-prescription-labels The authors surveyed pharmacies in the Bronx, New York, and found …

6908. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36437/psn-pdf
      June 06, 2018 - Promethazine conundrum: IV can hurt more than IM injection! June 6, 2018 ISMP Medication Safety Alert! Acute Care Edition. November 2, 2006;11:1-3. https://psnet.ahrq.gov/issue/promethazine-conundrum-iv-can-hurt-more-im-injection This article describes instances of tissue injury as a result of the misadministratio…

6909. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35161/psn-pdf
      March 13, 2016 - The forgotten tourniquet—an update. March 13, 2016 PA Patient Saf Advis. 2016;13(1):4. http://patientsafety.pa.gov/ADVISORIES/Pages/201603_32.aspx. https://psnet.ahrq.gov/issue/forgotten-tourniquet-update This advisory from the Pennsylvania Patient Safety Reporting System discusses 1079 reports of tourniquets bein…

6910. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36607/psn-pdf
      February 28, 2015 - Consumer Guide to Adverse Health Events. February 28, 2015 St Paul, MN: Minnesota Department of Health; 2015. https://psnet.ahrq.gov/issue/consumer-guide-adverse-health-events This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care pos…

6911. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36096/psn-pdf
      September 28, 2010 - How a series of errors led to recurrent hypoglycemia. September 28, 2010 Singh R. How a series of errors led to recurrent hypoglycemia. J Fam Pract. 2006;55(6):489-97. https://psnet.ahrq.gov/issue/how-series-errors-led-recurrent-hypoglycemia This case study illustrates how therapeutic duplication can lead to harm a…

6912. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35492/psn-pdf
      October 31, 2018 - Disclosure of Adverse Events to Patients. May 4, 2015 Department of Veterans Affairs, Washington DC: Veterans Health Administration; October 31, 2018. VHA Directive 1004.08. https://psnet.ahrq.gov/issue/disclosure-adverse-events-patients This Veterans Health Administration (VHA) directive provides direction for di…

6913. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35947/psn-pdf
      August 02, 2010 - AORN guidance statement: creating a patient safety culture. August 2, 2010 Nurses A of periOR. AORN guidance statement: creating a patient safety culture. AORN journal. 2006;83(4):936-42. https://psnet.ahrq.gov/issue/aorn-guidance-statement-creating-patient-safety-culture This article provides a framework of stra…

6914. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33945/psn-pdf
      March 17, 2011 - Massachusetts Coalition for the Prevention of Medical Errors. March 17, 2011 Massachusetts Coalition for the Prevention of Medical Errors https://psnet.ahrq.gov/issue/massachusetts-coalition-prevention-medical-errors The Massachusetts Coalition for the Prevention of Medical Errors was established to improve patien…

6915. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40987/psn-pdf
      February 22, 2017 - Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit. February 22, 2017 Bethesda, MD: Institute for Patient- and Family-Centered Care; 2011. https://psnet.ahrq.gov/issue/partnering-patients-and-families-enhance-safety-and-quality-mini-toolkit This toolkit provides strategies for enga…

6916. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34855/psn-pdf
      March 07, 2005 - Pharmacists play key role in patient safety. March 7, 2005 https://psnet.ahrq.gov/issue/pharmacists-play-key-role-patient-safety Description of a successful model from Duke University (SD), where hospital pharmacists play an integral role in patient care. They provide counseling for patients, support for medical te…

6917. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38182/psn-pdf
      October 29, 2008 - On the Edge: Nursing in the Age of Complexity. October 29, 2008 Lindberg C, Nash S, Lindberg C. Bordentown, NJ: PlexusPress; 2008. ISBN: 1438246765. https://psnet.ahrq.gov/issue/edge-nursing-age-complexity This book provides a foundation on complexity science concepts and examines how they can be applied to effect…

6918. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39809/psn-pdf
      September 01, 2010 - Medical Errors and Safety Systems. September 1, 2010 Pearlman MD, ed. Clin Obstet Gynecol. 2010;53(3):471-585.   https://psnet.ahrq.gov/issue/medical-errors-and-safety-systems This special issue provides articles that discuss leadership roles, human factors, risk management, and data collection concepts that …

6919. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35509/psn-pdf
      January 17, 2025 - Patient Safety Awareness Week. January 17, 2025 Institute for Healthcare Improvement. https://psnet.ahrq.gov/issue/patient-safety-awareness-week This website provides resources for promoting patient safety during Patient Safety Awareness Week, including a webinar archive, selected readings and communication strate…

6920. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36287/psn-pdf
      September 20, 2006 - Nursing Home Complaint Investigations.  September 20, 2006 Levinson DR. Washington DC: Office of the Inspector General; July 2006. OEI-01-04-00340. https://psnet.ahrq.gov/issue/nursing-home-complaint-investigations This report shares findings from an assessment of Centers for Medicaid and Medicare Services response…