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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47508/psn-pdfOctober 24, 2018 - Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. October 24, 2018 Soncrant CM, Warner LJ, Neily J, et al. Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration. AORN J. 2018;108(4):386-397. doi:10.1002/aorn.12372. https://psnet.ahrq.go… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44038/psn-pdfMay 06, 2015 - Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation. May 6, 2015 Marks L, Mazur L, Chera B, Adams R. Boca Raton, FL: Productivity Press; 2015. ISBN: 9781482233643. https://psnet.ahrq.gov/issue/engineering-patient-safety-radiation-oncology… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47317/psn-pdfAugust 15, 2018 - Actions Needed to Address Employee Misconduct Process and Ensure Accountability. August 15, 2018 Washington, DC: United States Government Accountability Office; July 2018. Publication GAO-18-137. https://psnet.ahrq.gov/issue/actions-needed-address-employee-misconduct-process-and-ensure- accountability Both organi… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39013/psn-pdfOctober 14, 2009 - The nature and causes of unintended events reported at ten emergency departments. October 14, 2009 Smits M, Groenewegen PP, Timmermans D, et al. The nature and causes of unintended events reported at ten emergency departments. BMC Emerg Med. 2009;9:16. doi:10.1186/1471-227X-9-16. https://psnet.ahrq.gov/issue/natur… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45400/psn-pdfAugust 10, 2016 - ISMP National Vaccine Errors Reporting Program: one in three vaccine errors associated with age-related factors. August 10, 2016 ISMP Medication Safety Alert! Acute Care Edition. July 28, 2016;21:1-6. https://psnet.ahrq.gov/issue/ismp-national-vaccine-errors-reporting-program-one-three-vaccine-errors- associated-a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866107/psn-pdfJune 12, 2024 - Hospital inpatient nutrition service errors and patient safety interventions: a scoping review. June 12, 2024 Austria D, McConnell C, Pope C. Hospital inpatient nutrition service errors and patient safety interventions: a scoping review. J Patient Saf. 2024;20(4):272-278. doi:10.1097/pts.0000000000001223. https://… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/867343/psn-pdfDecember 11, 2024 - Communication about harm reduction with patients who have opioid use disorder. December 11, 2024 Hawk M, Jawa R, Kay ES. Communication about harm reduction with patients who have opioid use disorder. JAMA. 2025;333(2):163-164. doi:10.1001/jama.2024.21307. https://psnet.ahrq.gov/issue/communication-about-harm-reduc… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43999/psn-pdfMay 19, 2018 - Label design affects medication safety in an operating room crisis: a controlled simulation study. May 19, 2018 Estock JL, Murray AW, Mizah MT, et al. Label Design Affects Medication Safety in an Operating Room Crisis: A Controlled Simulation Study. J Patient Saf. 2018;14(2):101-106. doi:10.1097/PTS.00000000000001… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/845353/psn-pdfMarch 01, 2023 - Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California. March 1, 2023 Washington, DC: VA Office of the Inspector General; February 2, 2023. Report no. 22-01363-52. https://psnet.ahrq.gov/issue/inadequate-outpatient-mental-health-triage-and… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50432/psn-pdfSeptember 04, 2019 - Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida. September 4, 2019 Washington, DC: Department of Veterans Affairs, Office of Inspector General. August 22, 2019. Report No. 19-07429-195. https://psnet.ahrq.gov/issue/patient-suicide-locked-mental-health-unit-west-palm… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/851925/psn-pdfAugust 02, 2023 - Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri. August 2, 2023 Washington DC: Department of Veterans Affairs, Office of Inspector General; June 29, 2023. Report no. 22-01540-146. https://psnet.ahrq.gov/iss… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73285/psn-pdfMay 19, 2021 - The mindful path to nursing accuracy: a quasi- experimental study on minimizing medication administration errors. May 19, 2021 Ekkens CL, Gordon PA. The mindful path to nursing accuracy: a quasi-experimental study on minimizing medication administration errors. Holist Nurs Pract. 2021;35(3):115-122. doi:10.1097/h… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46255/psn-pdfSeptember 06, 2017 - Patient Safety in the Home: Assessment of Issues, Challenges, and Opportunities. September 6, 2017 Carpenter D, Famolaro T, Hassell S, et al. Cambridge, MA: Institute for Healthcare Improvement; 2017. https://psnet.ahrq.gov/issue/patient-safety-home-assessment-issues-challenges-and-opportunities The ambulatory env… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45013/psn-pdfApril 13, 2016 - Good Practice Guides on Medication Errors: Part 1 and Part 2. April 13, 2016 Goedecke T, Ord K, Newbould V, et al. Medication Errors: New Eu Good Practice Guide On Risk Minimisation And Error Prevention. Springer Science and Business Media LLC; 2016. doi:10.1007/s40264- 016-0410-4. https://psnet.ahrq.gov/issue/go… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73062/psn-pdfJanuary 01, 2022 - Description of the role of pharmacist independent double checks during cognitive order verification of outpatient parenteral anti-cancer therapy. March 25, 2021 Booth JP, Kennerly-Shah JM, Hartman AD. Description of the role of pharmacist independent double checks during cognitive order verification of outpatient … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837697/psn-pdfJuly 20, 2022 - Outsourcing health-care services to the private sector and treatable mortality rates in England, 2013-20: an observational study of NHS privatisation. July 20, 2022 Goodair B, Reeves A. Outsourcing health-care services to the private sector and treatable mortality rates in England, 2013–20: an observational study … -
AHRQ Safety Program for Perinatal Care: Background Quality Improvement Team Information Form (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/team-info-form.docxMay 01, 2017 - AHRQ Safety Program for Perinatal Care: Background Quality Improvement Team Information Form AHRQ Safety Program for Perinatal Care Background Quality Improvement Team Information Form Who should use this tool? Health care teams Please indicate staff members designated as Labor and Delivery Quality Improvement Team… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44005/psn-pdfApril 08, 2015 - Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system. April 8, 2015 Schnoor J, Rogalski C, Frontini R, et al. Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system. Patient Saf Surg. 2015;9:12. doi:10.1186/s1303… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47498/psn-pdfMarch 05, 2019 - Data omission by physician trainees on ICU rounds. March 5, 2019 Artis KA, Bordley J, Mohan V, et al. Data Omission by Physician Trainees on ICU Rounds. Crit Care Med. 2019;47(3):403-409. doi:10.1097/CCM.0000000000003557. https://psnet.ahrq.gov/issue/data-omission-physician-trainees-icu-rounds Reporting complete p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73571/psn-pdfAugust 04, 2021 - "My whole room went into chaos because of that thing in the corner": unintended consequences of a central fetal monitoring system. August 4, 2021 Small K, Sidebotham M, Gamble J, et al. “My whole room went into chaos because of that thing in the corner”: unintended consequences of a central fetal monitoring system…
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