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5501. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38315/psn-pdf
      October 24, 2018 - Defusing Disruptive Behavior. A Workbook for Health Care Leaders. October 24, 2018 Oakbrook, IL: Joint Commission Resources; 2007. ISBN: 9781599400846. https://psnet.ahrq.gov/issue/defusing-disruptive-behavior-workbook-health-care-leaders This workbook includes background on disruptive behaviors and provides tools…

5502. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41492/psn-pdf
      June 27, 2018 - Alarm fatigue hazards: the sirens are calling. June 27, 2018 Welch J. https://psnet.ahrq.gov/issue/alarm-fatigue-hazards-sirens-are-calling This article reports on alarm fatigue in clinical care, including the risks associated with it, and describes tactics to help reduce nuisance alarms. https://psnet.ahrq.gov/i…

5503. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35824/psn-pdf
      July 24, 2008 - New standards for hospitals call for patients to get private rooms. July 24, 2008 Landro L. https://psnet.ahrq.gov/issue/new-standards-hospitals-call-patients-get-private-rooms This article reports on design guidelines that will require newly constructed hospitals to have only private rooms. Single-patient rooms …

5504. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41783/psn-pdf
      October 24, 2012 - How-to Guide: Prevent Obstetrical Adverse Events. October 24, 2012 Cambridge, MA: Institute for Healthcare Improvement; 2012. https://psnet.ahrq.gov/issue/how-guide-prevent-obstetrical-adverse-events This guide highlights strategies to enhance the use of care bundles to prevent errors in obstetric care. https://ps…

5505. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38153/psn-pdf
      October 15, 2008 - Geisinger Health System's plan to fix America's health care. October 15, 2008 Carbonara P. Fast Company. October 2008. https://psnet.ahrq.gov/issue/geisinger-health-systems-plan-fix-americas-health-care This magazine article describes how one health system is using an evidence-based, pay-for-performance program t…

5506. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36115/psn-pdf
      September 28, 2010 - Safe prescribing: an educational intervention for medical students. September 28, 2010 Garbutt J, DeFer TM, Highstein G, et al. Safe prescribing: an educational intervention for medical students. Teach Learn Med. 2006;18(3):244-50. https://psnet.ahrq.gov/issue/safe-prescribing-educational-intervention-medical-stud…

5507. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39661/psn-pdf
      November 02, 2010 - The value of 'gentle reminder' on safe medical behaviour. November 2, 2010 Erev I, Rodensky D, Levi M-A, et al. The value of 'gentle reminder' on safe medical behaviour. Qual Saf Health Care. 2010;19(5):e49. doi:10.1136/qshc.2009.032763. https://psnet.ahrq.gov/issue/value-gentle-reminder-safe-medical-behaviour Pee…

5508. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41681/psn-pdf
      January 01, 2013 - Patient safety in plastic surgery. September 12, 2012 Trussler AP, Tabbal GN. Patient safety in plastic surgery. Plast Reconstr Surg. 2013;130(3):470e-478e. doi:10.1097/prs.0b013e31825dc349. https://psnet.ahrq.gov/issue/patient-safety-plastic-surgery This commentary outlines tactics to prevent complications in pla…

5509. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37449/psn-pdf
      January 09, 2008 - Safety First: One Year On. January 9, 2008 London, England: National Patient Safety Agency; 2008. https://psnet.ahrq.gov/issue/safety-first-one-year This report shares the results of the British National Patient Safety Agency effort to reduce medical error and found that safety wasn’t always given the priority nec…

5510. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41362/psn-pdf
      June 15, 2012 - Non-Luer connectors: are we nearly there yet? June 15, 2012 Cook TM. Non-Luer connectors: are we nearly there yet? Anaesthesia. 2012;67(7):784-792. doi:10.1111/j.1365-2044.2012.07154.x. https://psnet.ahrq.gov/issue/non-luer-connectors-are-we-nearly-there-yet This commentary reviews progress in reducing wrong-route…

5511. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37764/psn-pdf
      January 21, 2011 - Overconfidence as a cause of diagnostic error in medicine. January 21, 2011 Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121(5 Suppl):S2-S23. doi:10.1016/j.amjmed.2008.01.001. https://psnet.ahrq.gov/issue/overconfidence-cause-diagnostic-error-medicine This compre…

5512. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36741/psn-pdf
      August 15, 2007 - Prescription for Improving Patient Safety: Addressing Medication Errors. August 15, 2007 The Medication Errors Panel. Sacramento, CA: California State Senate; March 2007.   https://psnet.ahrq.gov/issue/prescription-improving-patient-safety-addressing-medication-errors This report shares findings from an exper…

5513. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38462/psn-pdf
      June 24, 2010 - Care transitions and home health care. June 24, 2010 Boling PA. Care transitions and home health care. Clin Geriatr Med. 2009;25(1):135-48, viii. doi:10.1016/j.cger.2008.11.005. https://psnet.ahrq.gov/issue/care-transitions-and-home-health-care This article reviews the literature on transitions of care, discusses …

5514. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36156/psn-pdf
      September 29, 2010 - Addressing medication errors - the role of undergraduate nurse education. September 29, 2010 Page K, McKinney AA. Addressing medication errors--The role of undergraduate nurse education. Nurse Educ Today. 2007;27(3):219-24. https://psnet.ahrq.gov/issue/addressing-medication-errors-role-undergraduate-nurse-educatio…

5515. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41819/psn-pdf
      November 07, 2012 - Order from Chaos: Accelerating Care Integration. November 7, 2012 Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; October 2012. https://psnet.ahrq.gov/issue/order-chaos-accelerating-care-integration This report discusses the need for improved coordination and integration in patient car…

5516. Fire in the Hole!—An OR Fire | PSNet
      psnet.ahrq.gov/web-mm/fire-hole-or-fire
      August 03, 2017 - Fire in the Hole!—An OR Fire Citation Text: Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…

5517. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49787/psn-pdf
      March 01, 2017 - Diagnosing a Missed Diagnosis March 1, 2017 Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis The Case A 57-year old woman was admitted to the hospital with cough, slurred speech, confusion, and disorientation. She was taking mod…

5518. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
      May 01, 2017 - PowerPoint Presentation Spotlight Diagnostic Delay in the Emergency Department 1 Source and Credits This presentation is based on the May 2017 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Kyle Marshall, MD, Geisinger Medical Center, Danv…

5519. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33614/psn-pdf
      June 01, 2005 - Interpreting the Patient Safety Literature June 1, 2005 Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/interpreting-patient-safety-literature Perspective Five years ago, a widely publicized randomized trial reported a 90% reduction in the inciden…

5520. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60044/psn-pdf
      March 16, 2020 - Patient Safety in Medical, Nursing, and Other Clinical Education March 16, 2020 Howley LD, Hall KK, Fitall E. Patient Safety in Medical, Nursing, and Other Clinical Education . PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/patient-safety-medical-nursing-and-other-clinical-education Background Despit…