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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45391/psn-pdf
    August 10, 2016 - Where are my instruments? Hazards in delivery of surgical instruments. August 10, 2016 Guédon ACP, Wauben LSGL, van der Eijk AC, et al. Where are my instruments? Hazards in delivery of surgical instruments. Surg Endosc. 2016;30(7):2728-35. doi:10.1007/s00464-015-4537-7. https://psnet.ahrq.gov/issue/where-are-my-in…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43379/psn-pdf
    August 14, 2014 - Unit of measurement used and parent medication dosing errors. August 14, 2014 Yin S, Dreyer BP, Ugboaja DC, et al. Unit of measurement used and parent medication dosing errors. Pediatrics. 2014;134(2):e354-61. doi:10.1542/peds.2014-0395. https://psnet.ahrq.gov/issue/unit-measurement-used-and-parent-medication-dosi…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843323/psn-pdf
    February 01, 2023 - Long-Term Trends of Psychotropic Drug Use in Nursing Homes. February 1, 2023 Grimm CA. Washington DC: Office of the Inspector General; Nov 2022. Report no. OEI-07-20- 00500. https://psnet.ahrq.gov/issue/long-term-trends-psychotropic-drug-use-nursing-homes Misdiagnosis can result in inappropriate medication u…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60153/psn-pdf
    March 25, 2020 - A protocol for the safe use of hazardous drugs in the OR. March 25, 2020 Hemingway MW, Meleis L, Oliver J, et al. A protocol for the safe use of hazardous drugs in the OR. AORN J. 2020;111(3). doi:10.1002/aorn.12960. https://psnet.ahrq.gov/issue/protocol-safe-use-hazardous-drugs-or Perioperative personnel often ca…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74156/psn-pdf
    December 08, 2021 - Abusive supervision: a systematic review and fundamental rethink. December 8, 2021 Fischer T, Tian AW, Lee A, et al. Abusive supervision: a systematic review and fundamental rethink. The Leadership Q. 2021;32(6):101540. doi:10.1016/j.leaqua.2021.101540. https://psnet.ahrq.gov/issue/abusive-supervision-systematic-r…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46944/psn-pdf
    March 21, 2018 - Critical Deficiencies at the Washington DC VA Medical Center. March 21, 2018 Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. Report No. 17-02644-130. https://psnet.ahrq.gov/issue/critical-deficiencies-washington-dc-va-medical-center Systemic weaknesses in the Veterans A…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41173/psn-pdf
    February 29, 2012 - Root causes of errors in a simulated prehospital pediatric emergency. February 29, 2012 Lammers RL, Byrwa M, Fales W. Root causes of errors in a simulated prehospital pediatric emergency. Acad Emerg Med. 2012;19(1):37-47. doi:10.1111/j.1553-2712.2011.01252.x. https://psnet.ahrq.gov/issue/root-causes-errors-simulat…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837209/psn-pdf
    May 25, 2022 - Opioids and falls risk in older adults: a narrative review. May 25, 2022 Virnes R-E, Tiihonen M, Karttunen N, et al. Opioids and falls risk in older adults: a narrative review. Drugs Aging. 2022;39(3):199-207. doi:10.1007/s40266-022-00929-y. https://psnet.ahrq.gov/issue/opioids-and-falls-risk-older-adults-narrative…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865493/psn-pdf
    April 03, 2024 - Implement strategies to prevent persistent medication errors and hazards: 2024. April 3, 2024 ISMP Medication Safety Alert! Acute Care. 2024;29(6):1-4. https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards-2024 Systemic failures can perpetuate unsafe care if a lack of p…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42346/psn-pdf
    June 10, 2018 - Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. May 30, 2013;18:1-3. https://psnet.ahrq.gov/issue/fatal-pca-adverse-events-continue-happenbetter-patient-monitoring-essential- prevent-harm Describi…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50758/psn-pdf
    December 18, 2019 - Still Not Safe: Patient Safety and the Middle-Managing of American Medicine. December 18, 2019 Wears R, Sutcliffe K. New York, NY: Oxford University Press; 2019. ISBN: 9780190271268. https://psnet.ahrq.gov/issue/still-not-safe-patient-safety-and-middle-managing-american-medicine The modern patient safety movement …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844553/psn-pdf
    February 15, 2023 - Mental health conditions leading cause of pregnancy- related deaths. February 15, 2023 Quick Safety. January 16 2023;(67):1-3. https://psnet.ahrq.gov/issue/mental-health-conditions-leading-cause-pregnancy-related-deaths Maternal safety is compromised by a range of social, cognitive, and clinical factors. This arti…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847731/psn-pdf
    April 19, 2023 - Lessons from health care leaders: rethinking and reinvesting in patient safety. April 19, 2023 doi:10.1056/CAT.23.0090. https://psnet.ahrq.gov/issue/lessons-health-care-leaders-rethinking-and-reinvesting-patient-safety Progress in patient safety has been disappointingly slow. This commentary shares thoughts from a…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44991/psn-pdf
    April 20, 2016 - Does an insulin double-checking procedure improve patient safety? April 20, 2016 Modic MB, Albert NM, Sun Z, et al. Does an Insulin Double-Checking Procedure Improve Patient Safety? J Nurs Adm. 2016;46(3):154-60. doi:10.1097/NNA.0000000000000314. https://psnet.ahrq.gov/issue/does-insulin-double-checking-procedure-…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39110/psn-pdf
    June 10, 2018 - Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. November 5, 2009;14:1-3. https://psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time- leading-dru…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45756/psn-pdf
    December 21, 2016 - Accidental IV infusion of heparinized irrigation in the OR. December 21, 2016 ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3. https://psnet.ahrq.gov/issue/accidental-iv-infusion-heparinized-irrigation-or Accidental administration of irrigation solutions are a wrong-route error that can re…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45303/psn-pdf
    June 15, 2017 - The global burden of diagnostic errors in primary care. June 15, 2017 Singh H, Schiff G, Graber ML, et al. The global burden of diagnostic errors in primary care. BMJ Qual Saf. 2017;26(6):484-494. doi:10.1136/bmjqs-2016-005401. https://psnet.ahrq.gov/issue/global-burden-diagnostic-errors-primary-care The need to i…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47647/psn-pdf
    January 23, 2019 - Patient Safety: Global Action on Patient Safety. January 23, 2019 Executive Board EB144/29 144th session. Geneva, Switzerland: World Health Organization; December 12, 2018. https://psnet.ahrq.gov/issue/patient-safety-global-action-patient-safety This guidance summarizes the current status of global patient safety,…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43394/psn-pdf
    July 30, 2014 - With oral chemotherapy, we simply must do better! July 30, 2014 ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4. https://psnet.ahrq.gov/issue/oral-chemotherapy-we-simply-must-do-better To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38600/psn-pdf
    October 03, 2017 - Assessment of transparency of cost estimates in economic evaluations of patient safety programmes. October 3, 2017 Fukuda H, Imanaka Y. Assessment of transparency of cost estimates in economic evaluations of patient safety programmes. J Eval Clin Pract. 2009;15(3):451-9. doi:10.1111/j.1365-2753.2008.01033.x. https…
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