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7761. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45793/psn-pdf
      July 19, 2024 - SHOT Annual Report. July 19, 2024 S Narayan, ed. Manchester, UK: Serious Hazards of Transfusion (SHOT) Steering Group; 2023. ISBN: 9781999596859. https://psnet.ahrq.gov/issue/shot-annual-report-2019 Although errors in the blood transfusion process are rare, they can be harmful. This annual report provides an anal…

7762. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43921/psn-pdf
      February 18, 2015 - Is incivility an underlying threat to safety in obstetrics? February 18, 2015 Veltman L. Patient Saf Qual Healthc. January/February 2015;12:34-36. https://psnet.ahrq.gov/issue/incivility-underlying-threat-safety-obstetrics The Joint Commission and the American College of Obstetricians and Gynecologists have issued …

7763. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43738/psn-pdf
      December 03, 2014 - Unverified patient-reported error: a false alarm can have real consequences. December 3, 2014 ISMP Medication Safety Alert! Acute care edition. November 20, 2014;19:1-3. https://psnet.ahrq.gov/issue/unverified-patient-reported-error-false-alarm-can-have-real-consequences Reviewing an incident involving a patient w…

7764. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44155/psn-pdf
      June 24, 2015 - Patient Safety Tool Kit. June 24, 2015 WHO Regional Office for the Eastern Mediterranean. Cairo, Egypt: World Health Organization; 2015. ISBN: 9789290220596. https://psnet.ahrq.gov/issue/patient-safety-tool-kit Patient safety programs should reflect local needs, motivate clinician and leadership engagement, and s…

7765. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44880/psn-pdf
      September 06, 2016 - Drug shortages forcing hard decisions on rationing treatments. September 6, 2016 Fink S. New York Times. January 29, 2016. https://psnet.ahrq.gov/issue/drug-shortages-forcing-hard-decisions-rationing-treatments Drug shortages have become a routine challenge in medicine. Reporting on the impact of medication short…

7766. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38208/psn-pdf
      November 12, 2008 - Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories. November 12, 2008 Wagar EA, Stankovic AK, Raab SS, et al. Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories. Arch Pathol Lab Med. 2008;132(10):1617-22. doi:10.1043/1543- 2165(2008)132[1617:SLEAQA]2.0.CO;2. https:/…

7767. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40775/psn-pdf
      September 14, 2011 - Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania. September 14, 2011   Grissinger M, Dabliz R. Pa Patient Saf Advis 2011 Sep;8(3):85-93. https://psnet.ahrq.gov/issue/ambulatory-surgery-facilities-comprehensive-review-medication-error-reports- pennsylvania Anal…

7768. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43591/psn-pdf
      August 02, 2015 - The automated operating room: a team approach to patient safety and communication. August 2, 2015 Nissan J, Campos V, Delgado H, et al. The automated operating room: a team approach to patient safety and communication. JAMA Surg. 2014;149(11):1209-10. doi:10.1001/jamasurg.2014.1825. https://psnet.ahrq.gov/issue/au…

7769. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37155/psn-pdf
      October 06, 2011 - Classification of adverse events occurring in a surgical intensive care unit. October 6, 2011 Frankel H, Sperry J, Kaplan L, et al. Classification of adverse events occurring in a surgical intensive care unit. Am J Surg. 2007;194(3):328-32. https://psnet.ahrq.gov/issue/classification-adverse-events-occurring-surgi…

7770. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60926/psn-pdf
      September 16, 2020 - Sent home to die. September 16, 2020 Waldman A, Kaplan J. Sent home to die. ProPublica. 2020. https://psnet.ahrq.gov/issue/sent-home-die Hospitals have been deeply challenged to provide effective care during the COVID crisis. This article discusses how rationing and ineffective protection for families and patients…

7771. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41867/psn-pdf
      January 30, 2013 - Medication discrepancies in integrated electronic health records. January 30, 2013 Linsky A, Simon SR. Medication discrepancies in integrated electronic health records. BMJ Qual Saf. 2013;22(2):103-9. doi:10.1136/bmjqs-2012-001301. https://psnet.ahrq.gov/issue/medication-discrepancies-integrated-electronic-health-…

7772. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39783/psn-pdf
      August 25, 2010 - Ethics, oversight and quality improvement initiatives. August 25, 2010 Taylor HA, Pronovost PJ, Sugarman J. Ethics, oversight and quality improvement initiatives. Quality and Safety in Health Care. 2010;19(4). doi:10.1136/qshc.2009.038034. https://psnet.ahrq.gov/issue/ethics-oversight-and-quality-improvement-initia…

7773. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36771/psn-pdf
      January 22, 2017 - A pediatric medical emergency team manages a complex child with hypoxia and a worried parent. January 22, 2017 Shilkofski NA, Hunt EA. A pediatric medical emergency team manages a complex child with hypoxia and worried parent. Jt Comm J Qual Patient Saf. 2007;33(4):236-41, 185. https://psnet.ahrq.gov/issue/pediatr…

7774. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39103/psn-pdf
      November 18, 2009 - Identifying organizational cultures that promote patient safety. November 18, 2009 Singer SJ, Falwell A, Gaba DM, et al. Identifying organizational cultures that promote patient safety. Health Care Manag Rev. 2009;34(4):300-311. doi:10.1097/HMR.0b013e3181afc10c. https://psnet.ahrq.gov/issue/identifying-organizatio…

7775. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44383/psn-pdf
      January 05, 2017 - Field Guide to Collaborative Care: Implementing the Future of Health Care. January 5, 2017 Uhlig P, Raboin WE. Overland Park, KS: Oak Prairie Health Press; 2015. ISBN: 9780991411290. https://psnet.ahrq.gov/issue/field-guide-collaborative-care-implementing-future-health-care This online resource provides instructio…

7776. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40658/psn-pdf
      August 03, 2011 - Development and validation of a tool to improve paediatric referral/consultation communication. August 3, 2011 Stille CJ, Mazor KM, Meterko V, et al. Development and validation of a tool to improve paediatric referral/consultation communication. BMJ Qual Saf. 2011;20(8):692-7. doi:10.1136/bmjqs.2010.045781. https:…

7777. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37758/psn-pdf
      March 10, 2011 - Informatics opportunities: the intersection of patient safety and clinical informatics. March 10, 2011 Kilbridge PM, Classen D. The informatics opportunities at the intersection of patient safety and clinical informatics. J Am Med Inform Assoc. 2008;15(4):397-407. doi:10.1197/jamia.M2735. https://psnet.ahrq.gov/is…

7778. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73897/psn-pdf
      September 29, 2021 - Peer Support Toolkit. September 29, 2021 Betsy Lehman Center for Patient Safety. September 2021. https://psnet.ahrq.gov/issue/peer-support-toolkit Clinicians involved in adverse events that harm patients can struggle to come to terms with error. This toolkit is designed to assist organizations in the development o…

7779. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38698/psn-pdf
      June 10, 2009 - Towards a framework to select techniques for error prediction: supporting novice users in the healthcare sector. June 10, 2009 Lyons M. Towards a framework to select techniques for error prediction: supporting novice users in the healthcare sector. Appl Ergon. 2009;40(3):379-95. doi:10.1016/j.apergo.2008.11.004. …

7780. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45134/psn-pdf
      August 10, 2016 - Patient Safety: Exploring Quality of Care in the US. August 10, 2016 ProPublica, Inc. New York, NY. 2012-2016. https://psnet.ahrq.gov/issue/patient-safety-exploring-quality-care-us This website provides resources exploring patient safety challenges from various perspectives, including feature length articles and m…