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6081. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39807/psn-pdf
      December 29, 2014 - Perspectives in quality: designing the WHO Surgical Safety Checklist. December 29, 2014 Weiser TG, Haynes AB, Lashoher A, et al. Perspectives in quality: designing the WHO Surgical Safety Checklist. Int J Qual Health Care. 2010;22(5):365-70. doi:10.1093/intqhc/mzq039. https://psnet.ahrq.gov/issue/perspectives-qual…

6082. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42358/psn-pdf
      June 12, 2013 - CDC Grand Rounds: preventing unsafe injection practices in the U.S. health-care system. June 12, 2013 Prevention C for DC and. CDC grand rounds: preventing unsafe injection practices in the U.S. health-care system. MMWR Morb Mortal Wkly Rep. 2013;62(21):423-5. https://psnet.ahrq.gov/issue/cdc-grand-rounds-preventi…

6083. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39182/psn-pdf
      May 22, 2019 - ACOG Committee Opinion No. 447: patient safety in obstetrics and gynecology. May 22, 2019 Improvement AC of O and GCC on PS and Q. ACOG Committee Opinion No. 447: Patient safety in obstetrics and gynecology. Obstet Gynecol. 2009;114(6):1424-7. doi:10.1097/AOG.0b013e3181c6f90e. https://psnet.ahrq.gov/issue/acog-com…

6084. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50805/psn-pdf
      January 15, 2020 - Advancing safety with closed-loop communication of test results. January 15, 2020 Quick Safety. December 17, 2019;(52):1-3. https://psnet.ahrq.gov/issue/advancing-safety-closed-loop-communication-test-results Incomplete or delayed test result communication is a known factor in diagnostic error. This article shares…

6085. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846765/psn-pdf
      March 29, 2023 - Addressing Medical Gaslighting to Improve Maternal Health—Together. March 29, 2023 Oregon Patient Safety Commission: 2023. https://psnet.ahrq.gov/issue/addressing-medical-gaslighting-improve-maternal-health-together Gaslighting has been identified as a contributor to maternal mortality and morbidity. This toolkit …

6086. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41053/psn-pdf
      December 30, 2014 - Time to accelerate integration of human factors and ergonomics in patient safety. December 30, 2014 Gurses AP, Ozok A, Pronovost P. Time to accelerate integration of human factors and ergonomics in patient safety. BMJ Qual Saf. 2012;21(4):347-51. doi:10.1136/bmjqs-2011-000421. https://psnet.ahrq.gov/issue/time-acc…

6087. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46334/psn-pdf
      August 09, 2017 - Maternal deaths at MetroWest hospital prompt state probes. August 9, 2017 Kowalczyk L. Boston Globe. July 29, 2017. https://psnet.ahrq.gov/issue/maternal-deaths-metrowest-hospital-prompt-state-probes Maternal death is a sentinel event. This news article reports on two incidents at one hospital that prompted inves…

6088. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37359/psn-pdf
      January 02, 2017 - Case study: preventing surgical complications at Baystate Medical Center. January 2, 2017 Fitzgerald J, Kanter G, Benjamin EM. Case Study: Preventing Surgical Complications at Baystate Medical Center. The Joint Commission Journal on Quality and Patient Safety. 2016;33(11). doi:10.1016/s1553- 7250(07)33076-6. http…

6089. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74259/psn-pdf
      January 19, 2022 - Diagnostic reasoning in cardiovascular medicine. January 19, 2022 Brush JE, Sherbino J, Norman GR. Diagnostic reasoning in cardiovascular medicine. BMJ. 2022;376:e064389. doi:10.1136/bmj-2021-064389. https://psnet.ahrq.gov/issue/diagnostic-reasoning-cardiovascular-medicine Misdiagnosis of heart failure can lead to…

6090. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73872/psn-pdf
      September 22, 2021 - Parenteral nutrition safety. September 22, 2021 Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20. https://psnet.ahrq.gov/issue/parenteral-nutrition-safety Parenteral nutrition (PN) processes contain various steps that are prone to errors resulting in patient harm. This article discusses …

6091. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41683/psn-pdf
      September 19, 2012 - Techniques to improve patient safety in hospitals: what nurse administrators need to know. September 19, 2012 Fagan MJ. Techniques to improve patient safety in hospitals: what nurse administrators need to know. J Nurs Adm. 2012;42(9):426-430. doi:10.1097/NNA.0b013e3182664df5. https://psnet.ahrq.gov/issue/technique…

6092. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44678/psn-pdf
      July 05, 2017 - Patient Safety Risk Management Playbook. July 5, 2017 Chicago, IL: American Society for Healthcare Risk Management; 2015. https://psnet.ahrq.gov/issue/patient-safety-risk-management-playbook Proactive risk management is an important component to improving the safety of care. Exploring principles of high reliabilit…

6093. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/860400/psn-pdf
      January 10, 2024 - AHA Patient Safety Initiative. January 10, 2024 American Hospital Association. https://psnet.ahrq.gov/issue/aha-patient-safety-initiative Leadership at the organization and system level is crucial to gaining improvement traction and sustainability. This initiative centers on safety culture, care inequities, and wo…

6094. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60563/psn-pdf
      June 03, 2020 - ‘Last responders’ seek to expand postmortem COVID testing In unexplained deaths. June 3, 2020 Andrews M. Kaiser News Network. May 19, 2020. https://psnet.ahrq.gov/issue/last-responders-seek-expand-postmortem-covid-testing-unexplained-deaths Post-mortem examination is an important tool for determining if misdiagnos…

6095. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45646/psn-pdf
      November 23, 2016 - Patient safety in the emergency department. November 23, 2016 Farmer B. Patient Safety in the Emergency Department. Emerg Med (N Y). 2016;48(9). doi:10.12788/emed.2016.0052. https://psnet.ahrq.gov/issue/patient-safety-emergency-department Emergency departments are high-risk environments due to the urgency of care …

6096. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46494/psn-pdf
      January 24, 2018 - Complications. January 24, 2018 Anaesthesia. 2018;73(suppl 1):3-101. https://psnet.ahrq.gov/issue/complications Study of complications can provide insights into presurgical patient counseling, risk assessment, and medical harm prevention. Articles in this special issue explore complications in anesthesia, includin…

6097. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43151/psn-pdf
      April 30, 2014 - Open for Better Care. April 30, 2014 Health Quality & Safety Commission New Zealand. https://psnet.ahrq.gov/issue/open-better-care This Web site hosts tools and resources associated with a national campaign to augment patient care. The initiative aims to build collaborative programs across New Zealand to reduce fa…

6098. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867648/psn-pdf
      January 01, 2023 - Opioid Taskforce Playbook. January 1, 2023 College of Healthcare Information Management Executives; 2023. Opioid Taskforce Playbook. https://psnet.ahrq.gov/issue/opioid-taskforce-playbook Hospitals play an important role in identifying and preventing the misuse and abuse of prescription opioids. This Opioid Playbo…

6099. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39715/psn-pdf
      May 25, 2011 - Barriers to incident notification in a regional prehospital setting. May 25, 2011 Jennings PA, Stella J. Barriers to incident notification in a regional prehospital setting. Emerg Med J. 2011;28(6):526-9. doi:10.1136/emj.2010.090738. https://psnet.ahrq.gov/issue/barriers-incident-notification-regional-prehospital-…

6100. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47621/psn-pdf
      May 11, 2019 - 2018 update on pediatric medical overuse: a review. May 11, 2019 Coon ER, Quinonez RA, Morgan DJ, et al. 2018 Update on Pediatric Medical Overuse: A Review. JAMA Pediatr. 2019;173(4):379-384. doi:10.1001/jamapediatrics.2018.5550. https://psnet.ahrq.gov/issue/2018-update-pediatric-medical-overuse-review Overuse of …