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6201. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40430/psn-pdf
      October 18, 2011 - Eliminating CLABSI: A National Patient Safety Imperative. October 18, 2011 Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11- 0037-1-EF. https://psnet.ahrq.gov/issue/eliminating-clabsi-national-patient-safety-imperative This publication reports the impact hospital p…

6202. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45334/psn-pdf
      September 07, 2016 - Why 'Universal Precautions' are needed for medication lists. September 7, 2016 Shane R. Why 'Universal Precautions' are needed for medication lists. BMJ Qual Saf. 2016;25(9):731-2. doi:10.1136/bmjqs-2015-005116. https://psnet.ahrq.gov/issue/why-universal-precautions-are-needed-medication-lists Despite the support…

6203. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/844060/psn-pdf
      June 01, 2016 - Developing a measure of value in health care. June 1, 2016 Ken Lee KH, Matthew Austin J, Pronovost PJ. Developing a measure of value in health care. Value Health. 2015;19(4):323-325. doi:10.1016/j.jval.2014.12.009. https://psnet.ahrq.gov/issue/developing-measure-value-health-care Value-based healthcare is emerging…

6204. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41625/psn-pdf
      December 02, 2014 - Effects of CPOE on provider cognitive workload: a randomized crossover trial. December 2, 2014 Avansino J, Leu MG. Effects of CPOE on provider cognitive workload: a randomized crossover trial. Pediatrics. 2012;130(3):e547-52. doi:10.1542/peds.2011-3408. https://psnet.ahrq.gov/issue/effects-cpoe-provider-cognitive-…

6205. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45747/psn-pdf
      December 21, 2016 - Implementing No Interruption Zones in the perioperative environment. December 21, 2016 Wright I. Implementing No Interruption Zones in the Perioperative Environment. AORN J. 2016;104(6):536- 540. doi:10.1016/j.aorn.2016.09.018. https://psnet.ahrq.gov/issue/implementing-no-interruption-zones-perioperative-environme…

6206. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836754/psn-pdf
      March 16, 2022 - State of science: evolving perspectives on ‘human error’. March 16, 2022 Read GJM, Shorrock S, Walker GH, et al. State of science: evolving perspectives on ‘human error’. Ergonomics. 2021;64(9):1091-1114. doi:10.1080/00140139.2021.1953615. https://psnet.ahrq.gov/issue/state-science-evolving-perspectives-human-error…

6207. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43415/psn-pdf
      September 10, 2014 - Project BOOST implementation: lessons learned. September 10, 2014 Williams M, Li J, Hansen LO, et al. Project BOOST implementation: lessons learned. South Med J. 2014;107(7):455-65. doi:10.14423/SMJ.0000000000000140. https://psnet.ahrq.gov/issue/project-boost-implementation-lessons-learned This qualitative study o…

6208. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35628/psn-pdf
      June 23, 2010 - Medical professional liability insurance and its relation to medical error and healthcare risk management for the practicing physician. June 23, 2010 Abbott RL, Weber P, Kelley B. Medical professional liability insurance and its relation to medical error and healthcare risk management for the practicing physician.…

6209. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43562/psn-pdf
      September 24, 2014 - What's that sound? Managing alarm fatigue. September 24, 2014 George TP, Martin V. What?s that sound? Managing alarm fatigue. Nursing Made Incredibly Easy!. 2014;12(5). doi:10.1097/01.nme.0000452689.19763.3f. https://psnet.ahrq.gov/issue/whats-sound-managing-alarm-fatigue Alarm fatigue has been described as a cont…

6210. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41510/psn-pdf
      July 11, 2012 - Dangerous connections: health care community tackles tubing risks, small-bore connector standards. July 11, 2012 Vockley M. Joint Commission: The Source. June 2012;10:15-17. https://psnet.ahrq.gov/issue/dangerous-connections-health-care-community-tackles-tubing-risks-small- bore-connector This newsletter article …

6211. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47765/psn-pdf
      February 20, 2019 - Negative behaviours in health care: prevalence and strategies. February 20, 2019 Layne DM, Nemeth LS, Mueller M, et al. Negative behaviours in health care: Prevalence and strategies. J Nurs Manag. 2019;27(1):154-160. doi:10.1111/jonm.12660. https://psnet.ahrq.gov/issue/negative-behaviours-health-care-prevalence-an…

6212. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46469/psn-pdf
      October 25, 2017 - RxAwareness. October 25, 2017 Centers for Disease Control and Prevention; CDC. https://psnet.ahrq.gov/issue/rxawareness The opioid crisis is a persisting patient safety problem. One approach to prevent misuse of opioids is to raise awareness of the addictive nature of the medication. This national campaign enlists…

6213. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46477/psn-pdf
      January 08, 2018 - The iatrogenic potential of the physician's words. January 8, 2018 Barsky AJ. The Iatrogenic Potential of the Physician's Words. JAMA. 2017;318(24):2425-2426. doi:10.1001/jama.2017.16216. https://psnet.ahrq.gov/issue/iatrogenic-potential-physicians-words Inadequate information sharing between physicians and patien…

6214. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72688/psn-pdf
      October 06, 2022 - Request for proposals for clinical quality measures to improve diagnosis. October 6, 2022 Palo Alto CA; Gordon and Betty Moore Foundation: February 22, 2022.  https://psnet.ahrq.gov/issue/request-proposals-clinical-quality-measures-improve-diagnosis A lack of consensus on measures for the effectiveness and ac…

6215. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43734/psn-pdf
      January 21, 2015 - Explicit and Standardized Prescription Medicine Instructions. January 21, 2015 Rockville, MD: Agency for Healthcare Research and Quality; December 2014. https://psnet.ahrq.gov/issue/explicit-and-standardized-prescription-medicine-instructions Standardization has been embraced as a strategy to improve health litera…

6216. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47196/psn-pdf
      October 17, 2018 - Adaptive expertise in medical decision making. October 17, 2018 Croskerry P. Adaptive expertise in medical decision making. Med Teach. 2018;40(8):803-808. doi:10.1080/0142159X.2018.1484898. https://psnet.ahrq.gov/issue/adaptive-expertise-medical-decision-making Clinical reasoning is a complex process that can be i…

6217. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/864386/psn-pdf
      March 13, 2024 - Time for prefilled syringes - everywhere. March 13, 2024 Whitaker DK, Lomas JP. Time for prefilled syringes – everywhere. Anaesthesia. 2024;79(2):119-122. doi:10.1111/anae.16181. https://psnet.ahrq.gov/issue/time-prefilled-syringes-everywhere Simplifying complex processes is a strategy to engineer safety into heal…

6218. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37555/psn-pdf
      February 14, 2018 - ACOG Committee Opinion #730: fatigue and patient safety. February 14, 2018 ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2018;131(2):e78- e81. https://psnet.ahrq.gov/issue/acog-committee-opinion-730-fatigue-and-patient-safety This commentary discusses how sleep deprivation affects…

6219. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/764408/psn-pdf
      March 02, 2022 - Ensuring critical instruments and devices are appropriate for reuse. March 2, 2022 Quick Safety. February 14, 2022;(64):1-3. https://psnet.ahrq.gov/issue/ensuring-critical-instruments-and-devices-are-appropriate-reuse Complete, appropriate reprocessing and sterilization of reusable medical instruments and devices …

6220. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/839830/psn-pdf
      November 09, 2022 - Walgreens will stop judging its pharmacy staffers by how fast they work. November 9, 2022 Kaplan A. NBC News. October 27, 2022.  https://psnet.ahrq.gov/issue/walgreens-will-stop-judging-its-pharmacy-staffers-how-fast-they-work Suboptimal working conditions are a known contributor to errors in retail pharmacie…