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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838085/psn-pdf
    September 14, 2022 - Administering High-Strength Insulin from a Pen Device in Hospital. September 14, 2022 Farnborough, UK: Healthcare Safety Investigation Branch; July 7, 2022. https://psnet.ahrq.gov/issue/administering-high-strength-insulin-pen-device-hospital Misuse of insulin pens contributes to never events associated with diabet…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837346/psn-pdf
    June 08, 2022 - Decontamination of Surgical Instruments. June 8, 2022 Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022. https://psnet.ahrq.gov/issue/decontamination-surgical-instruments Surgical equipment sterilization can be hampered by equipment design, production pressures, process complexity and policy mi…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865597/psn-pdf
    April 17, 2024 - Discharge from Mental Health Care: Making it Safe and Patient-centred. April 17, 2024 Manchester, UK: Parliamentary and Health Service Ombudsman; March 2024. https://psnet.ahrq.gov/issue/discharge-mental-health-care-making-it-safe-and-patient-centred The provision of safe mental health care is receiving increased …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46636/psn-pdf
    January 24, 2018 - Drug shortages continue to compromise patient care. January 24, 2018 ISMP Medication Safety Alert! Acute Care Edition. January 11, 2018;23:1-4. https://psnet.ahrq.gov/issue/drug-shortages-continue-compromise-patient-care Drug shortages are known to disrupt the safety of care. This newsletter article reports the res…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46746/psn-pdf
    March 07, 2018 - Safety with nebulized medications requires an interdisciplinary team approach. March 7, 2018 ISMP Medication Safety Alert! Acute care edition. February 22, 2018;23(4):1-5. https://psnet.ahrq.gov/issue/safety-nebulized-medications-requires-interdisciplinary-team-approach Myriad system and clinician failures can con…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43084/psn-pdf
    May 19, 2014 - How can the criminal law support the provision of quality in healthcare? May 19, 2014 Yeung K, Horder J. How can the criminal law support the provision of quality in healthcare? BMJ Qual Saf. 2014;23(6):519-24. doi:10.1136/bmjqs-2013-002688. https://psnet.ahrq.gov/issue/how-can-criminal-law-support-provision-quali…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44298/psn-pdf
    July 08, 2015 - Preparing challenging medications for barcode scanning. July 8, 2015 Waxlax TJ. Preparing challenging medications for barcode scanning. Am J Health Syst Pharm. 2015;72(13):1089-90. doi:10.2146/ajhp140454. https://psnet.ahrq.gov/issue/preparing-challenging-medications-barcode-scanning Barcode scanning can reduce me…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47994/psn-pdf
    July 16, 2019 - What's in a name? Newborn naming conventions and wrong-patient errors. July 16, 2019 ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019. https://psnet.ahrq.gov/issue/whats-name-newborn-naming-conventions-and-wrong-patient-errors Newborns assigned temporary names are at increased risk for patient misi…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44243/psn-pdf
    November 09, 2015 - Concept analysis: wrong-site surgery. November 9, 2015 Watson DS. Concept analysis: wrong-site surgery. AORN J. 2015;101(6):650-6. doi:10.1016/j.aorn.2015.03.012. https://psnet.ahrq.gov/issue/concept-analysis-wrong-site-surgery Despite large-scale efforts to prevent wrong-site surgeries, they continue to occur. Th…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42750/psn-pdf
    November 20, 2013 - Serious hazards of transfusion (SHOT) haemovigilance and progress is improving transfusion safety. November 20, 2013 Bolton-Maggs PHB, Cohen H. Serious Hazards of Transfusion (SHOT) haemovigilance and progress is improving transfusion safety. Br J Haematol. 2013;163(3):303-14. doi:10.1111/bjh.12547. https://psnet.…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42551/psn-pdf
    May 21, 2019 - Should medical malpractice prevention be considered separately or as an integral part of comprehensive health care safety improvement? May 21, 2019 Enbom JA. Should medical malpractice prevention be considered separately or as an integral part of comprehensive health care safety improvement? Am J Obstet Gynecol. 2…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46748/psn-pdf
    February 08, 2019 - Safety culture, patient safety, and quality of care outcomes: a literature review. February 8, 2019 Lee SE, Scott LD, Dahinten S, et al. Safety Culture, Patient Safety, and Quality of Care Outcomes: A Literature Review. West J Nurs Res. 2019;41(2):279-304. doi:10.1177/0193945917747416. https://psnet.ahrq.gov/issue…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42582/psn-pdf
    September 18, 2013 - When diagnostic testing leads to harm: a new outcomes- based approach for laboratory medicine. September 18, 2013 Epner PL, Gans JE, Graber ML. When diagnostic testing leads to harm: a new outcomes-based approach for laboratory medicine. BMJ Qual Saf. 2013;22 Suppl 2:ii6-ii10. doi:10.1136/bmjqs-2012-001621. https:…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46059/psn-pdf
    July 11, 2017 - Pathologists' perspectives on disclosing harmful pathology error. July 11, 2017 Dintzis SM, Clennon EK, Prouty CD, et al. Pathologists' Perspectives on Disclosing Harmful Pathology Error. Arch Pathol Lab Med. 2017;141(6):841-845. doi:10.5858/arpa.2016-0136-OA. https://psnet.ahrq.gov/issue/pathologists-perspectives…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45404/psn-pdf
    August 31, 2016 - Error disclosure in pathology and laboratory medicine: a review of the literature. August 31, 2016 Perkins IU. Error Disclosure in Pathology and Laboratory Medicine: A Review of the Literature. AMA J Ethics. 2016;18(8):809-16. doi:10.1001/journalofethics.2016.18.8.nlit1-1608. https://psnet.ahrq.gov/issue/error-dis…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44090/psn-pdf
    November 21, 2016 - Insensible losses: when the medical community forgets the family. November 21, 2016 Elias P. Insensible losses: when the medical community forgets the family. Health Aff (Millwood). 2015;34(4):707-710. doi:10.1377/hlthaff.2014.0536. https://psnet.ahrq.gov/issue/insensible-losses-when-medical-community-forgets-fami…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41565/psn-pdf
    December 21, 2014 - Pursuing professional accountability: an evidence-based approach to addressing residents with behavioral problems. December 21, 2014 Sanfey H, DaRosa DA, Hickson GB, et al. Pursuing professional accountability: an evidence-based approach to addressing residents with behavioral problems. Arch Surg. 2012;147(7):642-…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44200/psn-pdf
    February 18, 2019 - Structured handover in general surgery: an audit of current practice. February 18, 2019 Jones HG, Watt B, Lewis L, et al. Structured Handover in General Surgery: An Audit of Current Practice. J Patient Saf. 2019;15(1):7-10. doi:10.1097/PTS.0000000000000201. https://psnet.ahrq.gov/issue/structured-handover-general-…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39656/psn-pdf
    July 07, 2010 - Is the test result correct? A questionnaire study of blood collection practices in primary health care. July 7, 2010 Söderberg J, Wallin O, Grankvist K, et al. Is the test result correct? A questionnaire study of blood collection practices in primary health care. J Eval Clin Pract. 2010;16(4):707-711. doi:10.1111/j…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851367/psn-pdf
    July 12, 2023 - A hard look at hard stops and workarounds in the acute care setting. July 12, 2023 ISMP Medication Safety Alert! Acute care edition. June 29, 2023;28(13);1-4. https://psnet.ahrq.gov/issue/hard-look-hard-stops-and-workarounds-acute-care-setting Hard stops in the electronic medical record prevent continuation of ord…
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