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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72584/psn-pdf
    December 16, 2020 - Hidden medication loss when using a primary administration set for small-volume intermittent infusions. December 16, 2020 ISMP Medication Safety Alert! Acute care edition. December 3, 2020;25(24). https://psnet.ahrq.gov/issue/hidden-medication-loss-when-using-primary-administration-set-small-volume- intermittent …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35417/psn-pdf
    February 15, 2010 - Errors in laboratory medicine: practical lessons to improve patient safety. February 15, 2010 Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab Med. 2005;129(10):1252-1261. https://psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patie…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867085/psn-pdf
    November 06, 2024 - The medication kit conundrum: considerations to enhance safety and efficiency. November 6, 2024 Arthur KJ, Fuller J, Dossett HA, et al. The medication kit conundrum: considerations to enhance safety and efficiency. Am J Health Syst Pharm. 2024;Epub Sep 4. doi:10.1093/ajhp/zxae233. https://psnet.ahrq.gov/issue/medi…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60564/psn-pdf
    June 03, 2020 - Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts? June 3, 2020 ISMP Medication Safety Alert! Acute Care Edition. May 22, 2020;25(10). https://psnet.ahrq.gov/issue/subtherapeutic-heparin-infusions-your-organization-risk-bypassing-soft-low- dose-alerts Smart infusion …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47850/psn-pdf
    March 27, 2019 - Medicines-related harm in the elderly post-hospital discharge. March 27, 2019 Cheong V-L, Tomlinson J, Khan S, et al. Prescriber. 2019;30:29-34. https://psnet.ahrq.gov/issue/medicines-related-harm-elderly-post-hospital-discharge Geriatric patients are particularly vulnerable to medication-related harm. This articl…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846465/psn-pdf
    March 22, 2023 - Difficult diagnosis in the ICU: making the right call but beware uncertainty and bias. March 22, 2023 Pisciotta W, Arina P, Hofmaenner D, et al. Difficult diagnosis in the ICU: making the right call but beware uncertainty and bias. Anaesthesia. 2023;78(4):501-509. doi:10.1111/anae.15897. https://psnet.ahrq.gov/iss…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46526/psn-pdf
    December 22, 2018 - Risk factors for adverse events in emergency department procedural sedation for children. December 22, 2018 Bhatt M, Johnson DW, Chan J, et al. Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatr. 2017;171(10):957-964. doi:10.1001/jamapediatrics.2017.2135. https:…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43412/psn-pdf
    May 28, 2015 - An observational study of how patients are identified before medication administrations in medical and surgical wards. May 28, 2015 Härkänen M, Kervinen M, Ahonen J, et al. An observational study of how patients are identified before medication administrations in medical and surgical wards. Nurs Health Sci. 2015;1…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867179/psn-pdf
    January 01, 2025 - Implementation of a standardized tool for root cause analysis selection. November 20, 2024 Wahlstedt E, Levy BE, Scott E, et al. Implementation of a standardized tool for root cause analysis selection. J Patient Saf. 2025;21(2):101-105. doi:10.1097/pts.0000000000001291. https://psnet.ahrq.gov/issue/implementation-…

  10. List of Tables and Exhibits | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/tables-exhibits.html
    August 01, 2022 - Designing Consumer Reporting Systems for Patient Safety Events List of Tables and Exhibits Previous Page Next Page Table of Contents Designing Consumer Reporting Systems for Patient Safety Events Executive Summary Chapter 1. Background Chapter 2. Conceptual Framework and Design Chapter 3. De…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45790/psn-pdf
    January 11, 2017 - Analysis of reported drug interactions: a recipe for harm to patients. January 11, 2017 Grissinger M. PA-PSRS Patient Saf Advis. December 2016;13:137-148. https://psnet.ahrq.gov/issue/analysis-reported-drug-interactions-recipe-harm-patients Drawing from reports of medication errors submitted over a 7-year period t…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43361/psn-pdf
    July 16, 2014 - An Avoidable Death of a Three-year-old Child from Sepsis. July 16, 2014 London, UK: Parliamentary and Health Service Ombudsman; June 2014. https://psnet.ahrq.gov/issue/avoidable-death-three-year-old-child-sepsis This investigation outlines how inadequate care contributed to the death of a child who developed sepsi…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50710/psn-pdf
    December 04, 2019 - Safety in office-based anesthesia: an updated review of the literature from 2016 to 2019 December 4, 2019 de Lima A, Osman BM, Shapiro FE. Safety in office-based anesthesia. Curr Opin Anaesthesiol. 2019;32(6):749-755. doi:10.1097/aco.0000000000000794. https://psnet.ahrq.gov/issue/safety-office-based-anesthesia-upd…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60648/psn-pdf
    July 01, 2020 - Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives. July 1, 2020 Osterholm MT, Olshaker M. Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives. Foreign Affairs. 2020;99:4. https://psnet.ahrq.gov/issue/chronicle-pan…

  15. Event Investigation and Analysis Guide: Appendix H | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/aph.html
    August 01, 2022 - Event Investigation and Analysis Guide: Appendix H Hierarchy of Solutions Do solutions meet the following criteria: Address the root cause/contributing factor. Are specific and concrete. Can be understood and implemented by a reader unfamiliar with the situation. Will be tested or simulated prior to…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73284/psn-pdf
    May 19, 2021 - Safety participation at the direct care level: results of a patient questionnaire. May 19, 2021 Duhn L, Gumapac N, Medves J. Safety participation at the direct care level: results of a patient questionnaire. Patient Exp J. 2021;8(1):59-68. doi:10.35680/2372-0247.1506. https://psnet.ahrq.gov/issue/safety-participat…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43385/psn-pdf
    August 06, 2014 - Medicines management support to older people: understanding the context of systems failure. August 6, 2014 Rogers S, Martin G, Rai G. Medicines management support to older people: understanding the context of systems failure. BMJ Open. 2014;4(7):e005302. doi:10.1136/bmjopen-2014-005302. https://psnet.ahrq.gov/issu…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43968/psn-pdf
    April 24, 2015 - Mental models: a basic concept for human factors design in infection prevention. April 24, 2015 Sax H, Clack L. Mental models: a basic concept for human factors design in infection prevention. J Hosp Infect. 2015;89(4):335-9. doi:10.1016/j.jhin.2014.12.008. https://psnet.ahrq.gov/issue/mental-models-basic-concept-…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43937/psn-pdf
    May 05, 2018 - Getting closer to the bull's eye: 2014–2015 Targeted Medication Safety Best Practices. May 5, 2018 ISMP Medication Safety Alert! Acute Care Edition. February 12, 2015;20:1-5. https://psnet.ahrq.gov/issue/getting-closer-bulls-eye-2014-2015-targeted-medication-safety-best-practices Benchmarks tracking a wide spectru…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44738/psn-pdf
    May 21, 2016 - The Habits of an Improver. Thinking About Learning for Improvement in Health Care. May 21, 2016 Lucas B, Nacer H. London, UK: Health Foundation; October 2015. ISBN: 9781906461676. https://psnet.ahrq.gov/issue/habits-improver-thinking-about-learning-improvement-health-care Committed leadership is essential to enhan…
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