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psnet.ahrq.gov/node/840167/psn-pdf
November 16, 2022 - 'Reading the Signals' : Maternity and Neonatal Services in
East Kent – the Report of the Independent Investigation.
November 16, 2022
Kirkup B. Department of Health and Social Care. London, England: Crown Copyright; 2022. ISBN:
9781528636759.
https://psnet.ahrq.gov/issue/reading-signals-maternity-and-neonata…
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psnet.ahrq.gov/node/44183/psn-pdf
November 03, 2015 - The absence of a drug–disease interaction alert leads to a
child's death.
November 3, 2015
ISMP Medication Safety Alert! Acute Care Edition. May 21, 2015;20:1-4.
https://psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death
The disabling of alerts due to alarm fatigue can hinder the abilit…
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psnet.ahrq.gov/node/73253/psn-pdf
May 12, 2021 - Any new process poses a risk for errors: learning from 4
months of Coronavirus disease 2019 (COVID-19)
vaccinations.
May 12, 2021
ISMP Medication Safety Alert! Acute Care Edition. April 22, 2021.26(8):1-5.
https://psnet.ahrq.gov/issue/any-new-process-poses-risk-errors-learning-4-months-coronavirus-disease-
2019-c…
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psnet.ahrq.gov/node/853062/psn-pdf
August 30, 2023 - Quality and safety practices among academic obstetrics
and gynecology departments.
August 30, 2023
Christopher D, Leininger WM, Beaty L, et al. Quality and safety practices among academic obstetrics and
gynecology departments. Am J Med Qual. 2023;38(4):165-173. doi:10.1097/jmq.0000000000000129.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/45625/psn-pdf
November 01, 2017 - Building comprehensive strategies for obstetric safety:
simulation drills and communication.
November 1, 2017
Austin N, Goldhaber-Fiebert SN, Daniels K, et al. Building Comprehensive Strategies for Obstetric Safety:
Simulation Drills and Communication. Anesth Analg. 2016;123(5):1181-1190.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/46717/psn-pdf
April 16, 2018 - Reduction in opioid prescribing through evidence-based
prescribing guidelines.
April 16, 2018
Howard R, Waljee JF, Brummett CM, et al. Reduction in Opioid Prescribing Through Evidence-Based
Prescribing Guidelines. JAMA Surg. 2018;153(3):285-287. doi:10.1001/jamasurg.2017.4436.
https://psnet.ahrq.gov/issue/reductio…
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psnet.ahrq.gov/node/867020/psn-pdf
October 23, 2024 - What can we learn from coroners’ reports on preventable
deaths?
October 23, 2024
Jeraj S. What can we learn from coroners’ reports on preventable deaths? BMJ. 2024;386:q1943.
https://psnet.ahrq.gov/issue/what-can-we-learn-coroners-reports-preventable-deaths
Analysis of system failure is only the beginning of the i…
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psnet.ahrq.gov/node/45679/psn-pdf
January 03, 2018 - Global Guidelines on the Prevention of Surgical Site
Infection.
January 3, 2018
Global Guidelines on the Prevention of Surgical Site Infection.
https://psnet.ahrq.gov/issue/global-guidelines-prevention-surgical-site-infection
Efforts to reduce surgical site infections have achieved some success. The World Health O…
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psnet.ahrq.gov/node/865880/psn-pdf
May 15, 2024 - Racial and ethnic harm in patient care is a patient safety
issue.
May 15, 2024
Rosario N, Kiles TM, M. Jewell T'B, et al. Racial and ethnic harm in patient care is a patient safety issue.
Res Social Adm Pharm. 2024;20(7):670-677. doi:10.1016/j.sapharm.2024.04.012.
https://psnet.ahrq.gov/issue/racial-and-ethnic-har…
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psnet.ahrq.gov/node/46311/psn-pdf
August 23, 2017 - Swimming against the tide: primary care physicians'
views on deprescribing in everyday practice.
August 23, 2017
Wallis KA, Andrews A, Henderson M. Swimming Against the Tide: Primary Care Physicians’ Views on
Deprescribing in Everyday Practice. Ann Fam Med. 2017;15(4):341-346. doi:10.1370/afm.2094.
https://psnet.a…
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psnet.ahrq.gov/node/43616/psn-pdf
October 29, 2014 - Preventing Healthcare-Associated Infections: Results and
Lessons Learned from AHRQ's HAI Program.
October 29, 2014
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Infect Control Hosp Epidemiol. 2014;35(suppl 3):S1-
S141.
https://psnet.ahrq.gov/issue/preventing-healthcare-associated-infections-results-and-lesson…
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psnet.ahrq.gov/node/36244/psn-pdf
June 13, 2012 - With Safety in Mind: Mental Health Services and Patient
Safety.
June 13, 2012
Scobie S, Minghella E, Dale C, et al. London, UK: National Patient Safety Agency; 2006.
https://psnet.ahrq.gov/issue/safety-mind-mental-health-services-and-patient-safety
This report, the second in a series from the United Kingdom's Nati…
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psnet.ahrq.gov/node/38070/psn-pdf
March 10, 2011 - Can surveillance systems identify and avert adverse drug
events? A prospective evaluation of a commercial
application.
March 10, 2011
Jha AK, Laguette J, Seger AC, et al. Can surveillance systems identify and avert adverse drug events? A
prospective evaluation of a commercial application. J Am Med Inform Assoc. 20…
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psnet.ahrq.gov/node/43213/psn-pdf
June 04, 2014 - Back to basics: preventing surgical site infections.
June 4, 2014
Spruce L. Back to basics: preventing surgical site infections. AORN J. 2014;99(5):600-8; quiz 609-11.
doi:10.1016/j.aorn.2014.02.002.
https://psnet.ahrq.gov/issue/back-basics-preventing-surgical-site-infections
Surgical site infections are a common …
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psnet.ahrq.gov/node/44072/psn-pdf
August 02, 2015 - The rise of the medical scribe industry: implications for
the advancement of electronic health records.
August 2, 2015
Gellert GA, Ramirez R, Webster L. The rise of the medical scribe industry: implications for the
advancement of electronic health records. JAMA. 2015;313(13):1315-1316. doi:10.1001/jama.2014.17128.
…
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psnet.ahrq.gov/node/35635/psn-pdf
June 24, 2010 - Patient safety problems in adolescent medical care.
June 24, 2010
Woods D, Holl JL, Klein JD, et al. Patient safety problems in adolescent medical care. J Adolesc Health.
2006;38(1):5-12.
https://psnet.ahrq.gov/issue/patient-safety-problems-adolescent-medical-care
Using data from the Colorado and Utah Medical Prac…
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psnet.ahrq.gov/node/45444/psn-pdf
December 04, 2016 - Alarm fatigue: use of an evidence-based alarm
management strategy.
December 4, 2016
Turmell JW, Coke L, Catinella R, et al. Alarm Fatigue. J Nurs Care Qual. 2016;32(1):47-54.
doi:10.1097/ncq.0000000000000223.
https://psnet.ahrq.gov/issue/alarm-fatigue-use-evidence-based-alarm-management-strategy
Reducing nuisance…
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psnet.ahrq.gov/node/46808/psn-pdf
February 14, 2018 - Anesthesia medication handling needs a new vision.
February 14, 2018
Grigg EB, Roesler A. Anesthesia Medication Handling Needs a New Vision. Anesth Analg.
2018;126(1):346-350. doi:10.1213/ANE.0000000000002521.
https://psnet.ahrq.gov/issue/anesthesia-medication-handling-needs-new-vision
Anesthesiology has been a le…
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psnet.ahrq.gov/node/841155/psn-pdf
February 02, 2020 - Understanding unwarranted variation in clinical practice:
a focus on network effects, reflective medicine and
learning health systems.
February 2, 2020
Atsma F, Elwyn G, Westert GP. Understanding unwarranted variation in clinical practice: a focus on
network effects, reflective medicine and learning health systems…
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psnet.ahrq.gov/node/34724/psn-pdf
May 27, 2011 - From patients to politicians: a cognitive engineering view
of patient safety.
May 27, 2011
Vicente KJ. From patients to politicians: a cognitive engineering view of patient safety. Qual Saf Health
Care. 2002;11(4):302-4.
https://psnet.ahrq.gov/issue/patients-politicians-cognitive-engineering-view-patient-safety
V…