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7441. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34002/psn-pdf
      March 17, 2011 - Utah DoH Patient Safety Initiatives. March 17, 2011 Center for Health Data, Utah Department of Health, PO Box 144004, Salt Lake City, UT 84114. https://psnet.ahrq.gov/issue/utah-doh-patient-safety-initiatives Utah established a number of collaborative initiatives to understand the nature and occurrence of adverse …

7442. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35013/psn-pdf
      March 22, 2015 - Using Human Factors Engineering to Improve Patient Safety, Second edition. March 22, 2015 Gosbee JW, Gosbee LL. Oakbrook, IL: Joint Commission; 2010. ISBN: 9781599404110. https://psnet.ahrq.gov/issue/using-human-factors-engineering-improve-patient-safety-second-edition This book provides a general introduction to …

7443. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35787/psn-pdf
      July 01, 2009 - Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. July 1, 2009 Rockville MD: Center for Devices and Radiological Health, Food and Drug Administration; 2006. https://psnet.ahrq.gov/issue/hospital-bed-system-dimensional-and-assessment-guidance-reduce- entrapment This document provides ba…

7444. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37473/psn-pdf
      December 27, 2014 - Communicating Critical Test Results. December 27, 2014 Burlington MA: Massachusetts Coalition for the Prevention of Medical Errors, MassPRO.  https://psnet.ahrq.gov/issue/communicating-critical-test-results-0 This set of materials provides checklists, worksheets, and other aids to help implement a reliable cri…

7445. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41562/psn-pdf
      August 01, 2012 - The Final Check: Say it Out Loud. August 1, 2012 https://psnet.ahrq.gov/issue/final-check-say-it-out-loud This Web site provides resources to help reduce incidence of mislabeled blood specimens based on just culture concepts. https://psnet.ahrq.gov/issue/final-check-say-it-out-loud https://psnet.ahrq.gov/web-mm/ri…

7446. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41233/psn-pdf
      March 21, 2012 - ASPEN Parenteral Nutrition Safety Summit. March 21, 2012 Andris DA, Mirtallo JM, Guenter P, eds. JPEN J Parenter Enteral Nutr. 2012;36(2 Suppl):1S-62S.   https://psnet.ahrq.gov/issue/aspen-parenteral-nutrition-safety-summit Articles in this special issue examine parenteral nutrition administration and provide …

7447. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37083/psn-pdf
      August 08, 2007 - Vincristine (and other vinca alkaloids) should only be given intravenously via a minibag. August 8, 2007 World Health Organization. Alert 115. July 18, 2007. https://psnet.ahrq.gov/issue/vincristine-and-other-vinca-alkaloids-should-only-be-given-intravenously- minibag This international announcement provides guid…

7448. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38074/psn-pdf
      June 04, 2018 - Questions and Answers on FDA's Adverse Event Reporting System (FAERS). October 3, 2017 Center for Drug Evaluation and Research, US Food and Drug Administration. June 4, 2018. https://psnet.ahrq.gov/issue/questions-and-answers-fdas-adverse-event-reporting-system-faers This FAQ provides information on and access to …

7449. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35503/psn-pdf
      February 22, 2010 - Neuroscience critical care: the role of the advanced practice nurse in patient safety. February 22, 2010 Phillips J. Neuroscience critical care: the role of the advanced practice nurse in patient safety. AACN Clin Issues. 2005;16(4):581-592. https://psnet.ahrq.gov/issue/neuroscience-critical-care-role-advanced-pra…

7450. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39911/psn-pdf
      June 10, 2018 - Drug shortages: national survey reveals high level of frustration, low level of safety. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. September 23, 2010:15:1-6. https://psnet.ahrq.gov/issue/drug-shortages-national-survey-reveals-high-level-frustration-low-level-safety This piece explores the effe…

7451. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38262/psn-pdf
      September 29, 2017 - Roadmap for patient safety research: approaches and roadforks. September 29, 2017 Hofoss D, Deilkås E. Roadmap for patient safety research: approaches and roadforks. Scand J Public Health. 2008;36(8):812-7. doi:10.1177/1403494808096168. https://psnet.ahrq.gov/issue/roadmap-patient-safety-research-approaches-and-ro…

7452. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37231/psn-pdf
      May 02, 2018 - Fluorouracil error ends tragically, but application of lessons learned will save lives. May 2, 2018 ISMP Medication Safety Alert! Acute care edition. September 20, 2007. https://psnet.ahrq.gov/issue/fluorouracil-error-ends-tragically-application-lessons-learned-will-save-lives This article summarizes an incident i…

7453. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36094/psn-pdf
      February 12, 2014 - Learning from Disasters: A Management Approach. Third ed. February 12, 2014 Toft B, Reynolds S. Leicester, UK: Perpetuity Press Limited; 2005. ISBN: 9781349279029. https://psnet.ahrq.gov/issue/learning-disasters-management-approach-third-ed This book provides a discussion of how organizations can learn from failur…

7454. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43259/psn-pdf
      June 11, 2014 - OpenFDA. June 11, 2014 US Food and Drug Administration; FDA. https://psnet.ahrq.gov/issue/openfda This Web site provides access to large publicly available datasets for adverse drug events to enable developers, researchers, and consumers to use this information when designing medication safety improvement plans o…

7455. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35925/psn-pdf
      July 26, 2010 - Safe medication prescribing and monitoring in the outpatient setting. July 26, 2010 Shojania KG. Safe medication prescribing and monitoring in the outpatient setting. Can Med Assoc J. 2006;174(9). doi:10.1503/cmaj.050984. https://psnet.ahrq.gov/issue/safe-medication-prescribing-and-monitoring-outpatient-setting T…

7456. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36474/psn-pdf
      May 26, 2011 - The checklist--a tool for error management and performance improvement. May 26, 2011 Hales BM, Pronovost P. The checklist--a tool for error management and performance improvement. J Crit Care. 2006;21(3):231-5. https://psnet.ahrq.gov/issue/checklist-tool-error-management-and-performance-improvement This commentar…

7457. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38135/psn-pdf
      June 28, 2011 - Content analysis of patient complaints. June 28, 2011 Montini T, Noble AA, Stelfox HT. Content analysis of patient complaints. Int J Qual Health Care. 2008;20(6):412-20. doi:10.1093/intqhc/mzn041. https://psnet.ahrq.gov/issue/content-analysis-patient-complaints This study developed a taxonomy for coding patient co…

7458. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37503/psn-pdf
      January 06, 2017 - Addressing postdischarge adverse events: a neglected area. January 6, 2017 Tsilimingras D. Addressing postdischarge adverse events: a neglected area. Jt Comm J Qual Patient Saf. 2008;34(2):85-97. https://psnet.ahrq.gov/issue/addressing-postdischarge-adverse-events-neglected-area This review examined the literatur…

7459. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39596/psn-pdf
      June 16, 2010 - Parents' perceptions of medical errors. June 16, 2010 Mazor KM, Goff SL, Dodd KS, et al. Parents' Perceptions of Medical Errors. J Patient Saf. 2010;6(2). doi:10.1097/pts.0b013e3181ddfcd0. https://psnet.ahrq.gov/issue/parents-perceptions-medical-errors This study found that perceived medical errors have a negative…

7460. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60737/psn-pdf
      July 29, 2020 - Second victim support programs for healthcare organizations. July 29, 2020 Stone M. Second victim support programs for healthcare organizations. Nurs Manage. 2020;51(6):38-45. https://psnet.ahrq.gov/issue/second-victim-support-programs-healthcare-organizations This literature review describes the types of second v…