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6041. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45226/psn-pdf
      January 04, 2017 - AHRQ Research Summit on Improving Diagnosis in Health Care. January 4, 2017 Rockville, MD; Agency for Healthcare Research and Quality: September 28, 2016. https://psnet.ahrq.gov/issue/ahrq-research-summit-improving-diagnosis-health-care Research is increasingly focusing on diagnostic errors and strategies to reduc…

6042. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37413/psn-pdf
      November 14, 2011 - Patient Safety Tools: Improving Safety at the Point of Care. November 14, 2011 https://psnet.ahrq.gov/issue/patient-safety-tools-improving-safety-point-care-0 Produced in conjunction with its Partnerships in Implementing Patient Safety (PIPS) grant program, AHRQ has released 17 freely available toolkits to help ho…

6043. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74766/psn-pdf
      June 24, 2024 - Patient handoffs. June 24, 2024 Arora V, Farnan J. UpToDate. June 24, 2024. https://psnet.ahrq.gov/issue/patient-handoffs-0 The change of an inpatient’s location or handoffs between teams can fragment care due to communication, information, and knowledge gaps. This review examines in-patient transition safety issu…

6044. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42447/psn-pdf
      July 24, 2013 - Economic Analysis of Medical Malpractice Liability and Its Reform. July 24, 2013 Arlen J. New York, NY: New York University School of Law; May 9, 2013. Public Law Research Paper No. 13-25.   https://psnet.ahrq.gov/issue/economic-analysis-medical-malpractice-liability-and-its-reform This report describes a ma…

6045. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61002/psn-pdf
      September 17, 2020 - Patient Safety September 17, 2020 Organisation for Economic Co-operation and Development. https://psnet.ahrq.gov/issue/patient-safety-21 Organizations worldwide are focusing efforts on reducing the conditions that contribute to medical error. This website provides a collection of reports and other resources that c…

6046. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42975/psn-pdf
      February 26, 2014 - State-Wide Initiative to Standardize the Compounding of Oral Liquids in Pediatrics. February 26, 2014 Michigan Pharmacists Association; MPA. https://psnet.ahrq.gov/issue/state-wide-initiative-standardize-compounding-oral-liquids-pediatrics Children are often prescribed oral liquid medications due to difficulty swa…

6047. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45291/psn-pdf
      November 30, 2016 - Just Bag It. November 30, 2016 National Comprehensive Cancer Network. https://psnet.ahrq.gov/issue/just-bag-it Vincristine is a chemotherapy agent that can have serious consequences if administered incorrectly. Drawing from guidelines and expert opinion regarding vincristine administration, this campaign advocates…

6048. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43233/psn-pdf
      June 17, 2014 - Quality and safety education for nurses: a nursing leadership skills exercise. June 17, 2014 Harrison EM. Quality and safety education for nurses: a nursing leadership skills exercise. J Nurs Educ. 2014;53(6):356-361. doi:10.3928/01484834-20140512-01. https://psnet.ahrq.gov/issue/quality-and-safety-education-nurse…

6049. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37788/psn-pdf
      May 28, 2008 - Durable improvements in efficiency, safety, and satisfaction in the operating room. May 28, 2008 Heslin MJ, Doster BE, Daily SL, et al. Durable improvements in efficiency, safety, and satisfaction in the operating room. J Am Coll Surg. 2008;206(5):1083-9; discussion 1089-90. doi:10.1016/j.jamcollsurg.2008.02.006. …

6050. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40951/psn-pdf
      December 21, 2014 - Quality and safety in medical care: what does the future hold? December 21, 2014 Liang BA, Mackey T. Quality and safety in medical care: what does the future hold? Arch Pathol Lab Med. 2011;135(11):1425-31. doi:10.5858/arpa.2011-0154-OA. https://psnet.ahrq.gov/issue/quality-and-safety-medical-care-what-does-future…

6051. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41075/psn-pdf
      January 18, 2012 - Wide heart monitor use tied to missed alarms. January 18, 2012 Funk M, Winkler CG, May JL, et al. Unnecessary arrhythmia monitoring and underutilization of ischemia and QT interval monitoring in current clinical practice: baseline results of the Practical Use of the Latest Standards for Electrocardiography trial. J…

6052. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50667/psn-pdf
      November 13, 2019 - Proactive prevention of maternal death from maternal hemorrhage. November 13, 2019 Quick Safety. October 29, 2019;(51):1-3. https://psnet.ahrq.gov/issue/proactive-prevention-maternal-death-maternal-hemorrhage The reduction of postpartum hemorrhage and the overall improvement of maternal safety is a patient safety …

6053. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38822/psn-pdf
      July 29, 2009 - The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited. July 29, 2009 Stahel PF, Mehler PS, Clarke TJ, et al. The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited. Patient Saf Surg. 2009;3(1):14. doi:10.1186/1754-9493-3-14. https://psnet.ahrq.gov/issue/5th-annivers…

6054. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43216/psn-pdf
      June 25, 2014 - Banning the handshake from the health care setting. June 25, 2014 Sklansky M, Nadkarni N, Ramirez-Avila L. Banning the handshake from the health care setting. JAMA. 2014;311(24):2477-8. https://psnet.ahrq.gov/issue/banning-handshake-health-care-setting Hand hygiene is an important practice that prevents transmissi…

6055. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72863/psn-pdf
      March 17, 2021 - 7 ways to prevent medical errors. March 17, 2021 Caceres V. US News World Report. March 1, 2021. https://psnet.ahrq.gov/issue/7-ways-prevent-medical-errors Patients and families have an important role in reducing potential for error and harm. This article highlights a set of tactics for patients to enhan…

6056. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36810/psn-pdf
      November 19, 2014 - A Systems Approach to Quality Improvement in Long- Term Care: Safe Medication Practices Workbook. November 19, 2014 Massachusetts Coalition for the Prevention of Medical Errors, MassPRO, Massachusetts Extended Care Foundation. Boston, MA: Commonwealth of Massachusetts; 2008. https://psnet.ahrq.gov/issue/systems-ap…

6057. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73520/psn-pdf
      July 21, 2021 - Geriatric medication reconciliation in the home setting. July 21, 2021 Taylor K. American Nurse J. 2021;16(7):14-17. https://psnet.ahrq.gov/issue/geriatric-medication-reconciliation-home-setting Medication reconciliation reduces the potential for problems in complicated medication regimens. This article share…

6058. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39344/psn-pdf
      March 03, 2010 - Mistake-proofing healthcare: why stopping processes may be a good start. March 3, 2010 Grout JR, Toussaint JS. Mistake-proofing healthcare: Why stopping processes may be a good start. Bus Horiz. 2009;53(2):149-156. doi:10.1016/j.bushor.2009.10.007. https://psnet.ahrq.gov/issue/mistake-proofing-healthcare-why-stopp…

6059. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47348/psn-pdf
      September 05, 2018 - Hospital-Acquired Condition Reduction Program (HACRP). September 5, 2018 QualityNet. Centers for Medicare and Medicaid Services. https://psnet.ahrq.gov/issue/hospital-acquired-condition-hac-reduction-program Eliminating hospital-acquired harm requires policy, organizational, and individual approaches to motivate …

6060. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850675/psn-pdf
      June 14, 2023 - Patient and Family Roles in Safety June 14, 2023 Johnson B, Lee M, Mossburg S. Patient and Family Roles in Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/patient-and-family-roles-safety Moving From Engagement to Partnership Involving patients and families in healthcare decisions about patient c…