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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44436/psn-pdf
    October 30, 2017 - Overreaction. October 30, 2017 Shell ER. Overreaction. Scientific American. 2015;313(5):28-9. https://psnet.ahrq.gov/issue/overreaction Reporting on how test inaccuracies can lead to misdiagnosis of food allergies in children and the potential consequences, this magazine article describes a diagnostic tool to dete…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39465/psn-pdf
    May 08, 2018 - Latest heparin fatality speaks loudly—what have you done to stop the bleeding? May 8, 2018 ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3. https://psnet.ahrq.gov/issue/latest-heparin-fatality-speaks-loudly-what-have-you-done-stop-bleeding Detailing a recent lethal overdose of heparin, this …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42344/psn-pdf
    September 24, 2016 - Strategies for preventing distractions and interruptions in the OR. September 24, 2016 Clark GJ. Strategies for preventing distractions and interruptions in the OR. AORN J. 2013;97(6):702-707. doi:10.1016/j.aorn.2013.01.018. https://psnet.ahrq.gov/issue/strategies-preventing-distractions-and-interruptions-or Dist…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37749/psn-pdf
    July 16, 2018 - Practice advisory for the prevention and management of operating room fires.  July 16, 2018 Fires AS of ATF on OR, Caplan RA, Barker SJ, et al. Practice advisory for the prevention and management of operating room fires. Anesthesiology. 2008;108(5):786-801; quiz 971-2. doi:10.1097/01.anes.0000299343.87119.a9. htt…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40668/psn-pdf
    March 04, 2015 - Body CT: technical advances for improving safety. March 4, 2015 Marin D, Nelson RC, Rubin GD, et al. Body CT: technical advances for improving safety. AJR Am J Roentgenol. 2011;197(1):33-41. doi:10.2214/AJR.11.6755. https://psnet.ahrq.gov/issue/body-ct-technical-advances-improving-safety This article explores risk…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35382/psn-pdf
    October 05, 2005 - Rx for a better prescription. Hospital bans doctors from using confusing medical abbreviations. October 5, 2005 Hall J. Fredericksburg Times. September 25, 2005 https://psnet.ahrq.gov/issue/rx-better-prescription-hospital-bans-doctors-using-confusing-medical- abbreviations This article presents one hospital’s pro…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46466/psn-pdf
    July 11, 2018 - Distinct newborn identification requirement. July 11, 2018 R3 Report. June 25, 2018;7:1-2. https://psnet.ahrq.gov/issue/distinct-newborn-identification-requirement Neonatal patients are at risk for misidentification due to communication challenges and lack of distinguishable features. This report highlights new Jo…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42830/psn-pdf
    December 18, 2013 - How to Identify and Address Unsafe Conditions Associated With Health IT. December 18, 2013 Wallace C, Zimmer KP, Possanza L, Giannini R, Solomon R. Washington, DC: Office of the National Coordinator for Health Information Technology; November 15, 2013. https://psnet.ahrq.gov/issue/how-identify-and-address-unsafe-c…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73431/psn-pdf
    June 23, 2021 - Drive to Deprescribe. June 23, 2021 The Society for Post-Acute and Long-Term Care Medicine. https://psnet.ahrq.gov/issue/drive-deprescribe Polypharmacy is a known challenge to patient safety. This collective program encourages long-term care organizations, physicians, and pharmacists to take part in a learning net…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42332/psn-pdf
    June 12, 2013 - Quality improvement through implementation of discharge order reconciliation. June 12, 2013 Lu Y, Clifford P, Bjorneby A, et al. Quality improvement through implementation of discharge order reconciliation. Am J Health Syst Pharm. 2013;70(9):815-20. doi:10.2146/ajhp120050. https://psnet.ahrq.gov/issue/quality-impr…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42753/psn-pdf
    November 20, 2013 - Dealing with a medical mistake: should physicians apologize to patients? November 20, 2013 Tabler NG Jr. https://psnet.ahrq.gov/issue/dealing-medical-mistake-should-physicians-apologize-patients This article discusses how apologies address patients' needs when a medical mistake has occurred and how such disclosur…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47556/psn-pdf
    November 28, 2018 - Improving Diagnosis. November 28, 2018 Deutsch E, ed. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):1-70. https://psnet.ahrq.gov/issue/improving-diagnosis This special issue raises awareness of challenges to reducing diagnostic error. Articles discuss insights from experts about how to improve diagnosis, t…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49652/psn-pdf
    May 01, 2012 - Double Dose at Transfer May 1, 2012 Hackman JL. Double Dose at Transfer. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/double-dose-transfer The Case A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department (ED) for left lower extremity pain, swelling, and erythe…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49566/psn-pdf
    July 01, 2008 - In fact, such testing has dramatically reduced the risk of viral transmission.

  15. Too Many Cooks in the Kitchen | PSNet

    psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
    March 07, 2018 - The team should strive for shorter surgical time, less tissue trauma and reduced need for fluid resuscitation

  16. What Was in Those Platelets? | PSNet

    psnet.ahrq.gov/web-mm/what-was-those-platelets
    August 28, 2024 - In fact, such testing has dramatically reduced the risk of viral transmission.

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41833/psn-pdf
    November 14, 2012 - Risks related to patient bed safety. November 14, 2012 Sharkey JE, Van Leuven K, Radovich P. Risks related to patient bed safety. J Nurs Care Qual. 2012;27(4):346-51. doi:10.1097/NCQ.0b013e318264744b. https://psnet.ahrq.gov/issue/risks-related-patient-bed-safety Reviewing the three major contributing factors to me…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41063/psn-pdf
    January 27, 2012 - Perspective: ten thousand hours to patient safety, sooner or later. January 27, 2012 Pellegrini VD. Perspective: ten thousand hours to patient safety, sooner or later. Acad Med. 2012;87(2):164-7. doi:10.1097/ACM.0b013e31823f7202. https://psnet.ahrq.gov/issue/perspective-ten-thousand-hours-patient-safety-sooner-or-…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42613/psn-pdf
    September 25, 2013 - Approaches to decreasing medication and other care errors in the ICU. September 25, 2013 Valentin A. Approaches to decreasing medication and other care errors in the ICU. Curr Opin Crit Care. 2013;19(5):474-9. doi:10.1097/MCC.0b013e328364d4f9. https://psnet.ahrq.gov/issue/approaches-decreasing-medication-and-other…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37087/psn-pdf
    October 03, 2011 - Improving patient safety in the ED waiting room. October 3, 2011 Blank FSJ, Santoro J, Maynard AM, et al. Improving patient safety in the ED waiting room. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Association. 2007;33(4):331-5. https://psnet.ahrq.gov/issue/improvin…
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