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121. Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center. | PSNet
     psnet.ahrq.gov/issue/one-pen-one-patient-achievable-hospital-quality-improvement-project-reduce-risks-inadvertent
     April 10, 2024 - blood-borne disease transmission associated with insulin pen sharing in hospitalized patients and provide recommendations … This paper describes the impact on insulin pen sharing after the implementation of safe practice recommendations … Resources Review of medication error sources associated with inpatient subcutaneous insulin: recommendations

122. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838256/psn-pdf
     October 05, 2022 - Reinforcing the Value and Roles of Nurses in Diagnostic Safety: Pragmatic Recommendations for Nurse … https://psnet.ahrq.gov/issue/reinforcing-value-and-roles-nurses-diagnostic-safety-pragmatic- recommendations-nurse-leaders … https://psnet.ahrq.gov/issue/reinforcing-value-and-roles-nurses-diagnostic-safety-pragmatic-recommendations-nurse-leaders … https://psnet.ahrq.gov/issue/reinforcing-value-and-roles-nurses-diagnostic-safety-pragmatic-recommendations-nurse-leaders

123. Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy. | PSNet
     psnet.ahrq.gov/issue/unintended-transplantation-three-organs-hiv-positive-donor-report-analysis-adverse-event
     January 24, 2018 - This case study discusses errors that contributed to transplantation of infected organs and provides recommendations … November 12, 2014 Supporting doctors as healthcare quality and safety advocates: recommendations … February 13, 2019 Undermining and bullying in surgical training: a review and recommendations … We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations

124. Using the Generic Analysis Method to analyze sentinel event reports across hospitals: a retrospective cross-sectional study. | PSNet
     psnet.ahrq.gov/issue/using-generic-analysis-method-analyze-sentinel-event-reports-across-hospitals-retrospective
     May 18, 2022 - severe patient harm and require a full organizational investigation to identify root causes and make recommendations … Aggregation of system-level factors may provide more urgency in implementing recommendations than a … October 25, 2023 Perioperative patient safety recommendations: systematic review of clinical

125. How does workplace violence-reporting culture affect workplace violence, nurse burnout, and patient safety? | PSNet
     psnet.ahrq.gov/issue/how-does-workplace-violence-reporting-culture-affect-workplace-violence-nurse-burnout-and
     February 08, 2023 - directed at healthcare workers in the US, the Joint Commission issued a Sentinel Event Alert and recommendations … This study evaluated the effect of one of those recommendations, a WPV-reporting culture, on nurses’ … November 9, 2022 Duplicate medication order errors: safety gaps and recommendations for

126. Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses and inpatient units. | PSNet
     psnet.ahrq.gov/issue/retrospective-analysis-reported-suicide-deaths-and-attempts-veterans-health-administration
     November 17, 2021 - suicide events in VA hospitals to characterize suicide attempts and deaths and provide prevention recommendations … Recommendations include avoidance of environmental hazards , medication monitoring, control of firearms … , 2020 Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations

127. Guidelines on Human Factors in Critical Situations 2023. | PSNet
     psnet.ahrq.gov/issue/guidelines-human-factors-critical-situations-2023
     November 29, 2023 - This guideline provides recommendations centered on elements of communication, the organization, the … : Causation and Prevention February 26, 2025 Perioperative patient safety recommendations … December 7, 2022 APSF endorsed statement on revising recommendations for patient monitoring

128. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41611/psn-pdf
     November 23, 2012 - Self-reported uptake of recommendations after dissemination of medication incident alerts. … Self-reported uptake of recommendations after dissemination of medication incident alerts. … https://psnet.ahrq.gov/issue/self-reported-uptake-recommendations-after-dissemination-medication- incident-alerts … Many pharmacies had yet to implement any of the recommendations 2 years after they were issued, and … only one of those recommendations had been implemented by a majority of pharmacies.

129. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60175/psn-pdf
     April 01, 2020 - ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID … https://psnet.ahrq.gov/issue/acr-recommendations-use-chest-radiography-and-computed-tomography-ct- suspected-covid … https://psnet.ahrq.gov/issue/acr-recommendations-use-chest-radiography-and-computed-tomography-ct-suspected-covid … -19 https://psnet.ahrq.gov/issue/acr-recommendations-use-chest-radiography-and-computed-tomography-ct-suspected-covid

130. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38538/psn-pdf
     January 02, 2017 - Rating recommendations for consumers about patient safety: sense, common sense, or nonsense? … Rating recommendations for consumers about patient safety: sense, common sense, or nonsense? … https://psnet.ahrq.gov/issue/rating-recommendations-consumers-about-patient-safety-sense-common- sense-or-nonsense … The investigators reviewed recommendations from 26 organizations and found wide variation in the types … Development of a unified set of recommendations for patients would likely help providers and patients

131. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43186/psn-pdf
     May 19, 2014 - ASPEN parenteral nutrition safety consensus recommendations: translation into practice. … A.S.P.E.N. parenteral nutrition safety consensus recommendations: translation into practice. … https://psnet.ahrq.gov/issue/aspen-parenteral-nutrition-safety-consensus-recommendations-translation- … https://psnet.ahrq.gov/issue/aspen-parenteral-nutrition-safety-consensus-recommendations-translation-practice … https://psnet.ahrq.gov/issue/aspen-parenteral-nutrition-safety-consensus-recommendations-translation-practice

132. FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing. | PSNet
     psnet.ahrq.gov/issue/fda-safety-communication-flexible-bronchoscopes-and-updated-recommendations-reprocessing
     March 11, 2015 - Release/Announcement FDA Safety Communication: flexible bronchoscopes and updated recommendations … Citation Text: FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing … Citation Citation Text: FDA Safety Communication: flexible bronchoscopes and updated recommendations

133. Improving operating room and perioperative safety: background and specific recommendations. | PSNet
     psnet.ahrq.gov/issue/improving-operating-room-and-perioperative-safety-background-and-specific-recommendations
     August 29, 2011 - Commentary Improving operating room and perioperative safety: background and specific recommendations … Improving operating room and perioperative safety: background and specific recommendations. … Improving operating room and perioperative safety: background and specific recommendations.

134. Procedural safety in emergency care: a conceptual model and recommendations. | PSNet
     psnet.ahrq.gov/issue/procedural-safety-emergency-care-conceptual-model-and-recommendations
     July 02, 2011 - Commentary Procedural safety in emergency care: a conceptual model and recommendations … Procedural safety in emergency care: a conceptual model and recommendations. … Procedural safety in emergency care: a conceptual model and recommendations.

135. Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples. | PSNet
     psnet.ahrq.gov/issue/letter-health-care-providers-safe-use-surgical-staplers-and-staples
     October 20, 2021 - Recommendations include ensuring availability of various staple sizes and avoiding use of staples on … August 20, 2021 FDA Safety Communication: flexible bronchoscopes and updated recommendations … March 28, 2012 New dosing recommendations to prevent potential Valcyte (valganciclovir

136. Using social and behavioural science to support COVID-19 pandemic response. | PSNet
     psnet.ahrq.gov/issue/using-social-and-behavioural-science-support-covid-19-pandemic-response
     March 02, 2022 - social and behavioral sciences perspective, the authors present insights for aligning behavior with recommendations … November 23, 2011 Implementing the 2009 Institute of Medicine recommendations on resident … wearing a face mask for prevention in the era of COVID-19 pandemic: a systematic review and consensus recommendations

137. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38290/psn-pdf
     February 17, 2011 - Revisiting duty-hour limits — IOM recommendations for patient safety and resident education. … Revisiting duty-hour limits--IOM recommendations for patient safety and resident education. … https://psnet.ahrq.gov/issue/revisiting-duty-hour-limits-iom-recommendations-patient-safety-and-resident … - education This editorial provides an overview of the 2008 Institute of Medicine recommendations for … The article notes that the new recommendations represent a compromise between the sometimes competing

138. Perioperative COVID-19 defense: an evidence-based approach for optimization of infection control and operating room management. | PSNet
     psnet.ahrq.gov/issue/perioperative-covid-19-defense-evidence-based-approach-optimization-infection-control-and
     November 30, 2012 - The authors describe eight empirical recommendations for optimizing infection control and operating room … Recommendations address (1) hand hygiene , (2) environmental cleaning , (3) patient decolonization, … Resources From the Same Author(s) Procedural safety in emergency care: a conceptual model and recommendations … We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations

139. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. | PSNet
     psnet.ahrq.gov/issue/resident-duty-hours-enhancing-sleep-supervision-and-safety
     July 12, 2016 - The Institute of Medicine's report bases its recommendations on the growing body of research linking … $1.7 billion would be required to hire additional staff to allow residency programs to adhere to these recommendations … patient safety, resident safety, and resident education that was central to the development of these recommendations … February 17, 2011 Revisiting duty-hour limits — IOM recommendations for patient safety

140. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40578/psn-pdf
     July 06, 2011 - Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision … Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision … https://psnet.ahrq.gov/issue/implementing-2009-institute-medicine-recommendations-resident-physician- … https://psnet.ahrq.gov/issue/implementing-2009-institute-medicine-recommendations-resident-physician-work-hours … https://psnet.ahrq.gov/issue/implementing-2009-institute-medicine-recommendations-resident-physician-work-hours