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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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.…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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 …
  15. Psn-Pdf (pdf file)

    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. …
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…

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