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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40298/psn-pdfMay 13, 2019 - Improving patient safety in radiation oncology. May 13, 2019 Hendee WR, Herman MG. Improving patient safety in radiation oncology. https://psnet.ahrq.gov/issue/improving-patient-safety-radiation-oncology This commentary discusses radiation safety issues and describes recommendations developed at a conference to re… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36437/psn-pdfJune 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… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40685/psn-pdfAugust 10, 2011 - Safety considerations for IMRT. August 10, 2011 Moran JM, Dempsey M, Eisbruch A, et al. Pract Radiat Oncol. 2011;1(suppl 1):1-33. https://psnet.ahrq.gov/issue/safety-considerations-imrt This white paper reveals expert opinion from the American Society of Radiation Oncology on intensity- modulated radiation … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37331/psn-pdfMay 02, 2018 - Product-related issues make error potential enormous with investigational drugs. May 2, 2018 ISMP Medication Safety Alert! Acute care edition. 2007;12(2):1-3. https://psnet.ahrq.gov/issue/product-related-issues-make-error-potential-enormous-investigational-drugs This article highlights numerous safety concerns sur… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40704/psn-pdfAugust 17, 2011 - Plan for quality to improve patient safety at the point of care. August 17, 2011 Ehrmeyer SS. Plan for Quality to Improve Patient Safety at the Point of Care. Ann Saudi Med. 2011;31(4). doi:10.4103/0256-4947.83203. https://psnet.ahrq.gov/issue/plan-quality-improve-patient-safety-point-care This review discusses t… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/35567/psn-pdfDecember 14, 2005 - USP initiatives for the safe use of medical gases. December 14, 2005 Zaidi K; Curry PD Jr; Becker SC. Pharm Tech. 2005. 29(11) https://psnet.ahrq.gov/issue/usp-initiatives-safe-use-medical-gases This article reports on recommendations developed by United States Pharmacopeia (USP) to improve the safety of using med… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/34631/psn-pdfDecember 23, 2016 - Sentinel Event Alert. December 23, 2016 Oakbrook Terrace, IL: The Joint Commission. https://psnet.ahrq.gov/issue/sentinel-event-alert This newsletter provides guidance to health care organizations for responding to commonly reported incidents. The Joint Commission issues these sentinel event alerts to review selec… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42108/psn-pdfMarch 13, 2013 - Distractions and their impact on patient safety. March 13, 2013 Feil M. PA-PSRS Patient Saf Advis. March 2013;10:1-10. https://psnet.ahrq.gov/issue/distractions-and-their-impact-patient-safety Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece outlines the types of distraction… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46870/psn-pdfMarch 14, 2018 - Opioid Wisely. March 14, 2018 Choosing Wisely Canada. https://psnet.ahrq.gov/issue/opioid-wisely Opioid misuse is a concern in both the United States and Canada. This campaign shares 19 specialty- specific recommendations to improve opioid safety in Canadian hospitals. An Annual Perspective discussed the opioid c… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36287/psn-pdfSeptember 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… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36877/psn-pdfMay 08, 2018 - Action needed to prevent dangerous heparin-insulin confusion. May 8, 2018 ISMP Medication Safety Alert! Acute care edition. May 3, 2007;12:1-2. https://psnet.ahrq.gov/issue/action-needed-prevent-dangerous-heparin-insulin-confusion This alert describes several incidents of heparin/insulin mix-ups and provides recom… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42813/psn-pdfDecember 04, 2016 - Patient Stories 2013: Time for Change. December 4, 2016 Harrow, Middlesex, UK: The Patients Association; 2013. https://psnet.ahrq.gov/issue/patient-stories-2013-time-change This publication provides patient and family accounts of incidents involving inadequate care or harm and highlights the need for improvements … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/36713/psn-pdfApril 29, 2018 - Reducing patient harm from opiates. April 29, 2018 ISMP Medication Safety Alert! Acute care edition. February 22, 2007. https://psnet.ahrq.gov/issue/reducing-patient-harm-opiates This article lists common risks associated with opiates, a high-alert medication, as well as recommended safety improvements to reduce t… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43276/psn-pdfJune 18, 2014 - Misidentification of alphanumeric symbols. June 18, 2014 ISMP Medication Safety Alert! Acute care edition. June 5, 2014;19:1-2,4-5. https://psnet.ahrq.gov/issue/misidentification-alphanumeric-symbols Written numbers and letters that look alike can contribute to miscommunication in a variety of settings. This newsl… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39846/psn-pdfFebruary 17, 2011 - Patient safety beyond the hospital. February 17, 2011 Gandhi TK, Lee TH. Patient safety beyond the hospital. N Engl J Med. 2010;363(11):1001-3. doi:10.1056/NEJMp1003294. https://psnet.ahrq.gov/issue/patient-safety-beyond-hospital This commentary discusses challenges for patient safety improvement work in the ambul… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38051/psn-pdfMay 05, 2018 - Misprogramming PCA concentration leads to dosing errors. May 5, 2018 ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3. https://psnet.ahrq.gov/issue/misprogramming-pca-concentration-leads-dosing-errors This article describes dosing errors associated with improper concentration programming of… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41857/psn-pdfNovember 21, 2012 - Stop the silent misdiagnosis: patients' preferences matter. November 21, 2012 Mulley AG, Trimble C, Elwyn G. Stop the silent misdiagnosis: patients' preferences matter. BMJ. 2012;345:e6572. doi:10.1136/bmj.e6572. https://psnet.ahrq.gov/issue/stop-silent-misdiagnosis-patients-preferences-matter This commentary des… -
www.ahrq.gov/research/shuttered/toolkitchecklist/gasvbase.htmlJuly 01, 2018 - Gas and Ventilation/Basement Inspect to determine whether to use existing or portable system. Date: ____________ Location: _______________________ Team member: __________________________ General Observations: Oxygen and Medical Gases Y N Is there an existing…
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digital.ahrq.gov/funding-mechanism/ahrq-patient-centered-outcomes-research-clinical-decision-support-learning-networkJanuary 01, 2023 - AHRQ Patient-Centered Outcomes Research Clinical Decision Support Learning Network (U18) Patient-Centered Outcomes Research Clinical Decision Support Learning Network Description The Patient-Centered Clinical Decision Support Learning Network was created as a multistakeholder …
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/34120/psn-pdfDecember 30, 2012 - Strategies for Hospitals to Improve Patient Safety: A Review of the Literature. December 30, 2012 Wong J, Beglaryan H. Toronto, ON: The Change Foundation; February 2004. https://psnet.ahrq.gov/issue/strategies-hospitals-improve-patient-safety-review-literature A literature review of preventable adverse events in a…
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