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5461. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33976/psn-pdf
      December 18, 2008 - Medical errors: overcoming the challenges. December 18, 2008 Kalra J. Medical errors: overcoming the challenges. Clin Biochem. 2004;37(12):1063-71. https://psnet.ahrq.gov/issue/medical-errors-overcoming-challenges This commentary introduces several initiatives intended to help reduce medical error, such as developm…

5462. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41471/psn-pdf
      June 20, 2012 - Patients taking their own medications while in the hospital. June 20, 2012 PA-PSRS Patient Saf Advis. June 2012;9:50-57.  https://psnet.ahrq.gov/issue/patients-taking-their-own-medications-while-hospital Discussing errors related to hospital patients' use of personal medications, this newsletter article provi…

5463. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39589/psn-pdf
      February 13, 2018 - Common cause analysis. February 13, 2018 Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35. https://psnet.ahrq.gov/issue/common-cause-analysis This article describes how one health care system used a multi-event analysis process to identify medication errors, implement system-level improvements, a…

5464. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38683/psn-pdf
      November 03, 2012 - Errors in Laboratory Medicine and Patient Safety. November 3, 2012 Plebani M, ed. Clinica Chimica Acta. 2009;404(1):1-86. https://psnet.ahrq.gov/issue/errors-laboratory-medicine-and-patient-safety This collection of papers presented at an international conference on laboratory medicine focuses on efforts to reduce…

5465. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37106/psn-pdf
      August 15, 2007 - Experts offer smart tips for smart pumps. August 15, 2007 Gebhart F. Drug Topics. July 23, 2007. https://psnet.ahrq.gov/issue/experts-offer-smart-tips-smart-pumps This article describes how robust drug libraries developed for programmable smart pumps can help reduce medication errors associated with traditional in…

5466. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39744/psn-pdf
      September 13, 2010 - Are you using checklists? Check! September 13, 2010 McNellis B, AAPA QCC of the. Are you using checklists? Check!. JAAPA. 2010;23(7):24-6, 31. https://psnet.ahrq.gov/issue/are-you-using-checklists-check This piece emphasizes how checklists can be effective tools to prevent medical error and reduce communication fa…

5467. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35320/psn-pdf
      September 14, 2005 - How business intelligence can improve patient safety. September 14, 2005 Wanless S, McManaway J. Metaphor Analytics. August 30, 2005. https://psnet.ahrq.gov/issue/how-business-intelligence-can-improve-patient-safety This article illustrates how hospitals can use their own administrative and patient data to reduce h…

5468. Advancement toward High Reliability in Healthcare Awards. | PSNet
      psnet.ahrq.gov/issue/advancement-toward-high-reliability-healthcare-awards
      June 08, 2011 - January 21, 2009 Teamwork is associated with reduced hospital staff burnout at military

5469. Fatal drug mix-up exposes hospital flaws. | PSNet
      psnet.ahrq.gov/issue/fatal-drug-mix-exposes-hospital-flaws
      March 02, 2016 - July 10, 2018 Teamwork is associated with reduced hospital staff burnout at military

5470. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39762/psn-pdf
      October 01, 2010 - Dennis Quaid's quest. August 18, 2010 Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91. https://psnet.ahrq.gov/issue/dennis-quaids-quest This article highlights how a medication error inspired Dennis Quaid to promote patient safety and chronicles his efforts to reduce harm in health care. https:/…

5471. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40077/psn-pdf
      July 10, 2012 - Improvement Cymru. July 10, 2012 NHS Wales. https://psnet.ahrq.gov/issue/improvement-cymru This national program draws from other large collaborative efforts to engage health care organizations across Wales in reducing preventable harm. It was rebranded from the 1000 Lives campaign in 2018. https://psnet.ahrq.gov…

5472. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42940/psn-pdf
      February 12, 2014 - Medical disrespect. February 12, 2014 Yurkiewicz I. Aeon Magazine. January 29, 2014. https://psnet.ahrq.gov/issue/medical-disrespect Disruptive behavior is a well-known and pervasive issue in health care. Describing disrespectful behaviors that clinicians face, such as sarcasm and intimidation, this magazine artic…

5473. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41919/psn-pdf
      December 12, 2012 - The best medicine for fixing the modern hospital. December 12, 2012 https://psnet.ahrq.gov/issue/best-medicine-fixing-modern-hospital This news article highlights how hospital design can help reduce infection rates, shorten length of stay, and improve patient safety. https://psnet.ahrq.gov/issue/best-medicine-fixi…

5474. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38917/psn-pdf
      September 06, 2013 - Health Care–Associated Infections. September 6, 2013 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/health-care-associated-infections For health care providers and consumers, this Web site features information, tools, and resources on health care–associated infections (HAIs). AHRQ-funded …

5475. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40481/psn-pdf
      June 20, 2011 - Medication errors—new approaches to prevention. June 20, 2011 Merry A, Anderson BJ. Medication errors--new approaches to prevention. Paediatr Anaesth. 2011;21(7):743-53. doi:10.1111/j.1460-9592.2011.03589.x. https://psnet.ahrq.gov/issue/medication-errors-new-approaches-prevention This review discusses evidence-bas…

5476. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43088/psn-pdf
      February 25, 2019 - ImproveDX. February 25, 2019 Society to Improve Diagnosis in Medicine. https://psnet.ahrq.gov/issue/improvedx Diagnostic errors have been termed the next frontier in patient safety. To raise awareness of this issue, this occasional newsletter features articles for a multidisciplinary audience that discuss barriers…

5477. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73128/psn-pdf
      July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. April 7, 2021 https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications- and-enhances Summary The Hospital at Homesm program provides hospital-level care…

5478. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
      January 01, 2024 - Spotlight Spotlight Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Christian Bohringer, MBBS, …

5479. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865429/psn-pdf
      April 24, 2024 - Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery April 24, 2024 Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery…

5480. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39776/psn-pdf
      January 25, 2017 - First, protect the patient from harm: applying adult learning principles to patient safety. January 25, 2017 Duffy B. https://psnet.ahrq.gov/issue/first-protect-patient-harm-applying-adult-learning-principles-patient-safety This piece describes how education can reduce patient harm by promoting attitude and behavi…