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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73429/psn-pdf
    June 23, 2021 - Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. June 23, 2021 Farnborough, UK: Healthcare Safety Investigation Branch; June 2021. https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings Wrong site/wrong patent surgery is a persisten…

  2. Conclusion | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-6.html
    March 01, 2022 - Improving Education—A Key to Better Diagnostic Outcomes Conclusion Previous Page Next Page Table of Contents Improving Education—A Key to Better Diagnostic Outcomes Introduction Foundations of Diagnosis Education Current State of Diagnosis Education Competencies To Improve Diagnosis in Healt…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47656/psn-pdf
    March 13, 2019 - Sleep and alertness in a duty-hour flexibility trial in internal medicine. March 13, 2019 Basner M, Asch DA, Shea JA, et al; iCOMPARE Research Group. N Engl J Med. 2019;380:915-923. https://psnet.ahrq.gov/issue/sleep-and-alertness-duty-hour-flexibility-trial-internal-medicine This cluster-randomized trial compared…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42642/psn-pdf
    October 09, 2013 - The contribution of prescription chart design and familiarity to prescribing error: a prospective, randomised, cross-over study. October 9, 2013 Tallentire VR, Hale RL, Dewhurst NG, et al. The contribution of prescription chart design and familiarity to prescribing error: a prospective, randomised, cross-over stud…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47473/psn-pdf
    December 05, 2018 - Holding out for an apology. December 5, 2018 Holding out for an apology. BMJ. 2018;363:k3033. doi:10.1136/bmj.k3033. https://psnet.ahrq.gov/issue/holding-out-apology Patients who experience care complications are vulnerable to psychological consequences that can affect their relationship with their clinical teams.…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47681/psn-pdf
    January 30, 2019 - Infection prevention in the operating room anesthesia work area. January 30, 2019 Munoz-Price S, Bowdle A, Johnston L, et al. Infection prevention in the operating room anesthesia work area. Infect Control Hosp Epidemiol. 2018:1-17. doi:10.1017/ice.2018.303. https://psnet.ahrq.gov/issue/infection-prevention-operat…

  7. Conclusion | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses5.html
    August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Conclusion Previous Page Next Page Table of Contents Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Introduction The Theory of Distributed Cognition Nurs…

  8. For Clinicians | Agency for Healthcare Research and Quality

    www.ahrq.gov/prevention/guidelines/tobacco/clinicians/index.html
    May 01, 2015 - For Clinicians All health care providers, especially those with direct patient contact, have a unique opportunity to help tobacco users quit. Smokers cite a doctor's advice to quit as an important motivator for attempting to stop smoking. Treating Tobacco Use and Dependence: 2008 Update—Clinical Practice …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47623/psn-pdf
    February 06, 2019 - Diagnostic heuristics in dermatology—part 1 and part 2. February 6, 2019 Lowenstein EJ, Sidlow R. Cognitive and visual diagnostic errors in dermatology: part 1 and part 2. J Dermatol. 2018;179(6):1263-1276. doi:10.1111/bjd.16932. https://psnet.ahrq.gov/issue/diagnostic-heuristics-dermatology-part-1-and-part-2 Cogn…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72829/psn-pdf
    March 10, 2021 - Safe Practices to Reduce CPOE Alert Fatigue through Monitoring, Analysis, and Optimization. March 10, 2021 Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021. https://psnet.ahrq.gov/issue/safe-practices-reduce-cpoe-alert-fatigue-through-monitoring-analysis-and- optimization Alert…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45952/psn-pdf
    May 31, 2017 - Surgeon, Heal Thyself: Optimising Surgical Performance by Managing Stress. May 31, 2017 Shiralkar U. Boca Raton, FL: CRC Press; 2017. ISBN: 9781498724036. https://psnet.ahrq.gov/issue/surgeon-heal-thyself-optimising-surgical-performance-managing-stress Stress, information overload, and high-risk decisions are prev…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43565/psn-pdf
    March 22, 2016 - The role of failure mode and effects analysis in health care. March 22, 2016 Fibuch E, Ahmed A. The role of failure mode and effects analysis in health care. Physician Exec. 2014;40(4):28-32. https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care Failure mode and effects analysis (FMEA) h…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837154/psn-pdf
    May 18, 2022 - Survey shows room for improvement with three new best practices for hospitals. May 18, 2022 ISMP Medication Safety Alert! Acute care edition. May 5, 2022;27(9):1-5.  https://psnet.ahrq.gov/issue/survey-shows-room-improvement-three-new-best-practices-hospitals Practice changes take time to be fully incorporate…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44417/psn-pdf
    January 25, 2016 - Health information exchange in emergency medicine. January 25, 2016 Shapiro JS, Crowley D, Hoxhaj S, et al. Health Information Exchange in Emergency Medicine. Ann Emerg Med. 2016;67(2):216-26. doi:10.1016/j.annemergmed.2015.06.018. https://psnet.ahrq.gov/issue/health-information-exchange-emergency-medicine Insuffi…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41803/psn-pdf
    December 16, 2013 - E-prescribing: a focused review and new approach to addressing safety in pharmacies and primary care. December 16, 2013 Odukoya OK, Chui MA. E-prescribing: a focused review and new approach to addressing safety in pharmacies and primary care. Res Social Adm Pharm. 2013;9(6):996-1003. doi:10.1016/j.sapharm.2012.09.…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60718/psn-pdf
    July 22, 2020 - First Do No Harm. The Report of the Independent Medicines and Medical Devices Safety Review. July 22, 2020 Cumberlege J. London, England, Crown Copyright. July 8, 2020. https://psnet.ahrq.gov/issue/first-do-no-harm-report-independent-medicines-and-medical-devices-safety- review Implicit biases are known to affect…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854382/psn-pdf
    October 11, 2023 - Battling alarm fatigue in the pediatric intensive care unit. October 11, 2023 Herrera H, Wood D. Battling alarm fatigue in the pediatric intensive care unit. Crit Care Nurs Clin North Am. 2023;35(3):347-355. doi:10.1016/j.cnc.2023.05.003. https://psnet.ahrq.gov/issue/battling-alarm-fatigue-pediatric-intensive-care-…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47958/psn-pdf
    June 26, 2019 - Patient safety professionals as the third victims of adverse events. June 26, 2019 Holden J, Card AJ. Patient safety professionals as the third victims of adverse events. J Patient Saf Risk Manag. 2019;24(4):166-175. doi:10.1177/2516043519850914. https://psnet.ahrq.gov/issue/patient-safety-professionals-third-vict…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45620/psn-pdf
    December 07, 2016 - A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes. December 7, 2016 Manojlovich M, Lee S, Lauseng D. A Systematic Review of the Unintended Consequences of Clinical Interventions to Reduce Adverse Outcomes. J Patient Saf. 2016;12(4):173-179. https://psnet.ahrq.g…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46254/psn-pdf
    October 09, 2017 - Using risk stratification to reduce medical errors in cervical cancer prevention. October 9, 2017 Perkins RB, Cain JM, Feldman S. Using Risk Stratification to Reduce Medical Errors in Cervical Cancer Prevention. JAMA Intern Med. 2017;177(10):1411-1412. doi:10.1001/jamainternmed.2017.3999. https://psnet.ahrq.gov/is…
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