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6681. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43997/psn-pdf
      August 02, 2015 - Sentinel events, serious reportable events, and root cause analysis. August 2, 2015 Chen TC, Schein OD, Miller JW. Sentinel events, serious reportable events, and root cause analysis. JAMA Ophthalmol. 2015;133(6):631-632. doi:10.1001/jamaophthalmol.2015.0672. https://psnet.ahrq.gov/issue/sentinel-events-serious-re…

6682. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850349/psn-pdf
      June 14, 2023 - Cognitive biases in internal medicine: a scoping review. June 14, 2023 Loncharich MF, Robbins RC, Durning SJ, et al. Cognitive biases in internal medicine: a scoping review. Diagnosis (Berl). 2023;10(3):205-214. doi:10.1515/dx-2022-0120. https://psnet.ahrq.gov/issue/cognitive-biases-internal-medicine-scoping-review…

6683. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46554/psn-pdf
      October 25, 2017 - Severe hyperglycemia in patients incorrectly using insulin pens at home. October 25, 2017 National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. October 12, 2017. https://psnet.ahrq.gov/issue/severe-hyperglycemia-patients-incorrect…

6684. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44724/psn-pdf
      November 25, 2015 - What's in your kit? A safety checkup may be in order. November 25, 2015 Paparella S. What's In Your Kit? A Safety Checkup May Be In Order. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Association. 2015;41(6):513-5. doi:10.1016/j.jen.2015.07.001. https://psnet.ahrq.gov…

6685. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73298/psn-pdf
      May 19, 2021 - The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. May 19, 2021 National Academies of Sciences, Engineering, and Medicine. Washington DC:  National Academies Press; 2021. ISBN: 9780309685061.  https://psnet.ahrq.gov/issue/future-nursing-2020-2030-charting-path-achieve-he…

6686. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44787/psn-pdf
      January 20, 2016 - Medication errors involving overrides of healthcare technology. January 20, 2016 Grissinger M. PA-PSRS Patient Saf Advis. December 2015;12:141-148. https://psnet.ahrq.gov/issue/medication-errors-involving-overrides-healthcare-technology Users often bypass alerts meant to enhance safety of medication ordering and d…

6687. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74724/psn-pdf
      February 02, 2022 - Using smart IV infusion pumps outside of patient rooms. February 2, 2022 Messing EG, Abraham RS, Quinn NJ, et al. Using smart IV infusion pumps outside of patient rooms. Am J Nurs. 2022;122(2). doi:10.1097/01.naj.0000819772.45006.5d. https://psnet.ahrq.gov/issue/using-smart-iv-infusion-pumps-outside-patient-rooms …

6688. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865974/psn-pdf
      May 29, 2024 - Minimizing bias when using artificial intelligence in critical care medicine. May 29, 2024 Ranard BL, Park S, Jia Y, et al. Minimizing bias when using artificial intelligence in critical care medicine. J Crit Care. 2024;82:154796. doi:10.1016/j.jcrc.2024.154796. https://psnet.ahrq.gov/issue/minimizing-bias-when-us…

6689. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43640/psn-pdf
      November 12, 2014 - Infection prevention in the emergency department. November 12, 2014 Liang SY, Theodoro DL, Schuur JD, et al. Infection prevention in the emergency department. Ann Emerg Med. 2014;64(3):299-313. doi:10.1016/j.annemergmed.2014.02.024. https://psnet.ahrq.gov/issue/infection-prevention-emergency-department Emergency c…

6690. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842434/psn-pdf
      June 01, 2024 - AHRQ Safety Program for Telemedicine. January 22, 2024 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/ahrq-safety-program-telemedicine Telemedicine efforts harbor both risk and reward to patients and clinicians. The AHRQ Safety Program for Telemedicine is a national effort to develop and …

6691. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74129/psn-pdf
      January 01, 2022 - Factors influencing providers' willingness to deprescribe medications. December 1, 2021 Davila H, Rosen AK, Stolzmann K, et al. Factors influencing providers' willingness to deprescribe medications. J Am Coll Clin Pharm. 2022;5:15-25. doi:10.1002/jac5.1537. https://psnet.ahrq.gov/issue/factors-influencing-provider…

6692. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866318/psn-pdf
      July 17, 2024 - Methods to increase reliability in quality improvement projects. July 17, 2024 Lenk MA, LaMantia S, Oehler J, et al. Methods to increase reliability in quality improvement projects. Hosp Pediatr. 2024;14(8):e372-e377. doi:10.1542/hpeds.2023-007340. https://psnet.ahrq.gov/issue/methods-increase-reliability-quality-…

6693. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43478/psn-pdf
      August 27, 2014 - Is it time to move beyond errors in clinical reasoning and discuss accuracy? August 27, 2014 Wood TJ. Is it time to move beyond errors in clinical reasoning and discuss accuracy? Adv Health Sci Educ Theory Pract. 2014;19(3):403-407. doi:10.1007/s10459-014-9498-4. https://psnet.ahrq.gov/issue/it-time-move-beyond-er…

6694. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/847733/psn-pdf
      March 16, 2025 - ISMP Targeted Medication Safety Best Practices for Community Pharmacy. March 16, 2025 Institute for Safe Medication Practices: March 2025. https://psnet.ahrq.gov/issue/ismp-targeted-medication-safety-best-practices-community-pharmacy Community pharmacies are common providers of medication delivery that harbor proc…

6695. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43565/psn-pdf
      March 22, 2016 - The role of failure mode and effects analysis in health care. March 22, 2016 Fibuch E, Ahmed A. The role of failure mode and effects analysis in health care. Physician Exec. 2014;40(4):28-32. https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care Failure mode and effects analysis (FMEA) h…

6696. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42539/psn-pdf
      September 27, 2016 - Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. September 27, 2016 Keers RN, Williams SD, Cooke J, et al. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Saf. 2013;36(1…

6697. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46020/psn-pdf
      July 21, 2017 - Towards high-reliability organising in healthcare: a strategy for building organisational capacity. July 21, 2017 Aboumatar HJ, Weaver SJ, Rees D, et al. Towards high-reliability organising in healthcare: a strategy for building organisational capacity. BMJ Qual Saf. 2017;26(8):663-670. doi:10.1136/bmjqs-2016-00624…

6698. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863757/psn-pdf
      March 06, 2024 - Debriefing to improve interprofessional teamwork in the operating room: a systematic review. March 6, 2024 Skegg E, McElroy C, Mudgway M, et al. Debriefing to improve interprofessional teamwork in the operating room: a systematic review. J Nurs Scholarsh. 2023;55(6):1179-1188. doi:10.1111/jnu.12924. https://psnet.…

6699. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44940/psn-pdf
      September 20, 2016 - Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. September 20, 2016 Lambe KA, O'Reilly G, Kelly BD, et al. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. BMJ Qual Saf. 2016;25(10):808-820. doi:10.1136/bmjqs-2015-004417. https://p…

6700. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73077/psn-pdf
      March 24, 2021 - Well-Being Playbook 2.0. A COVID-19 Resource for Hospital and Health System Leaders. March 24, 2021 AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.  https://psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders Human factors enginee…