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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47904/psn-pdf
    April 24, 2019 - Air pressure: human factors are the key to a safer flight environment. April 24, 2019 Erich J. EMS World. April 2019;48:26-31. https://psnet.ahrq.gov/issue/air-pressure-human-factors-are-key-safer-flight-environment Air transport service combines risks associated with both aviation and prehospital trauma care. Thi…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45549/psn-pdf
    October 12, 2016 - Preventing diagnostic errors in primary care. October 12, 2016 Ely JW, Graber ML. Preventing Diagnostic Errors in Primary Care. Am Fam Physician. 2016;94(6):426-32. https://psnet.ahrq.gov/issue/preventing-diagnostic-errors-primary-care The Improving Diagnosis in Health Care report advocated for enhancing patient en…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73256/psn-pdf
    May 12, 2021 - Addiction treatment providers in Pa. face little state scrutiny despite harm to clients. May 12, 2021 Pattani A, Mahon E. Kaiser Health News.  April 30, 2021. https://psnet.ahrq.gov/issue/addiction-treatment-providers-pa-face-little-state-scrutiny-despite-harm-clients Systemic oversight weaknesses and lack of…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39265/psn-pdf
    February 03, 2010 - Intensive care unit alarms—how many do we need? February 3, 2010 Siebig S, Kuhls S, Imhoff M, et al. Intensive care unit alarms--how many do we need? Crit Care Med. 2010;38(2):451-6. doi:10.1097/CCM.0b013e3181cb0888. https://psnet.ahrq.gov/issue/intensive-care-unit-alarms-how-many-do-we-need This study found that …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45048/psn-pdf
    April 13, 2016 - Do not let "Depo-" medications be a depot for mistakes. April 13, 2016 ISMP Medication Safety Alert! Acute Care Edition. March 24, 2016;21:1-4. https://psnet.ahrq.gov/issue/do-not-let-depo-medications-be-depot-mistakes Confusion due to look-alike and sound-alike medications are known to contribute to medication err…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43331/psn-pdf
    July 09, 2014 - Open wide: looking into the safety culture of dental school clinics. July 9, 2014 Ramoni R, Walji MF, Tavares A, et al. Open wide: looking into the safety culture of dental school clinics. J Dent Edu. 2014;78(5):745-756. https://psnet.ahrq.gov/issue/open-wide-looking-safety-culture-dental-school-clinics Researche…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74756/psn-pdf
    February 09, 2022 - Medication errors in overweight and obese pediatric patients: a systematic review. February 9, 2022 Procaccini D, Kim JM, Lobner K, et al. Medication errors in overweight and obese pediatric patients: a systematic review. Jt Comm J Qual Patient Saf. 2022;48(3):154-164. doi:10.1016/j.jcjq.2021.12.005. https://psnet…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851059/psn-pdf
    June 28, 2023 - Causes for medical errors in obstetrics and gynaecology. June 28, 2023 Klemann D, Rijkx M, Mertens H, et al. Causes for medical errors in obstetrics and gynaecology. Healthcare (Basel). 2023;11(11):1636. doi:10.3390/healthcare11111636. https://psnet.ahrq.gov/issue/causes-medical-errors-obstetrics-and-gynaecology R…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46081/psn-pdf
    April 19, 2017 - Why are medical errors still a leading cause of death? April 19, 2017 Headley M. https://psnet.ahrq.gov/issue/why-are-medical-errors-still-leading-cause-death This magazine article explores the need for robust research and effective reporting to better understand the prevalence of medical errors and how to prevent…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38276/psn-pdf
    December 10, 2008 - Addressing delays in medication administration for patients transferred from the hospital to the nursing home: a pilot quality improvement project. December 10, 2008 Ward KT, Bates-Jensen B, Eslami MS, et al. Addressing delays in medication administration for patients transferred from the hospital to the nursing h…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842431/psn-pdf
    January 11, 2023 - Confronting racism in pediatric care. January 11, 2023 Danielson B. Confronting racism in pediatric care. Health Affairs. 2022;41(11):1681-1685. doi:10.1377/hlthaff.2022.01157. https://psnet.ahrq.gov/issue/confronting-racism-pediatric-care Racism is a patient safety issue that is gaining the increased attention ne…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37117/psn-pdf
    October 04, 2011 - Language barriers to prescriptions for patients with limited English proficiency: a survey of pharmacies. October 4, 2011 Bradshaw M, Tomany-Korman S, Flores G. Language barriers to prescriptions for patients with limited English proficiency: a survey of pharmacies. Pediatrics. 2007;120(2):e225-35. https://psnet.a…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41826/psn-pdf
    June 03, 2013 - Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial. June 3, 2013 Altfeld SJ, Shier GE, Rooney M, et al. Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial. Gerontologist. 2013;53(3):430-40. doi:10.1093/geront…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45586/psn-pdf
    November 02, 2016 - Antimicrobial stewardship and patient safety. November 2, 2016 Zukowski CM. Antimicrobial Stewardship and Patient Safety. AORN J. 2016;104(4):354-356. doi:10.1016/j.aorn.2016.08.002. https://psnet.ahrq.gov/issue/antimicrobial-stewardship-and-patient-safety Antimicrobial stewardship has been highlighted as a strate…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47792/psn-pdf
    May 01, 2019 - New evidence on stemming low-value prescribing. May 1, 2019 Sacarny A, Barnett ML, Agrawal S. NEJM Catalyst. April 10, 2019. https://psnet.ahrq.gov/issue/new-evidence-stemming-low-value-prescribing Overprescribing contributes to polypharmacy, antibiotic resistance, and opioid misuse. This commentary discusses stra…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74276/psn-pdf
    January 19, 2022 - Guideline for Prevention of Unintentionally Retained Surgical Items. January 19, 2022 Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6. doi:10.1002/aorn.13579. https://psnet.ahrq.gov/issue/guideline-prevention-unintentionally-retained-surgical-items Retained su…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42985/psn-pdf
    February 26, 2014 - Confusion—specimen mix-up in dermatopathology and measures to prevent and detect it. February 26, 2014 Weyers W. Confusion-specimen mix-up in dermatopathology and measures to prevent and detect it. Dermatol Pract Concept. 2014;4(1):27-42. doi:10.5826/dpc.0401a04. https://psnet.ahrq.gov/issue/confusion-specimen-mix…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50809/psn-pdf
    January 15, 2020 - Electronic Health Record (EHR) Safety and Usability: See What We Mean. January 15, 2020 MedStar Health National Center for Human Factors in Healthcare. https://psnet.ahrq.gov/issue/electronic-health-record-ehr-safety-and-usability-see-what-we-mean Electronic health records (EHR) optimize information functions in c…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45801/psn-pdf
    August 03, 2017 - Overcoming diagnostic errors in medical practice. August 3, 2017 Bordini BJ, Stephany A, Kliegman RM. Overcoming Diagnostic Errors in Medical Practice. J Pediatr. 2017;185. doi:10.1016/j.jpeds.2017.02.065. https://psnet.ahrq.gov/issue/overcoming-diagnostic-errors-medical-practice This commentary describes a progra…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/858323/psn-pdf
    December 13, 2023 - Some doctors are ditching the scale, saying focusing on weight drives misdiagnoses. December 13, 2023 O'Neill E. Health Shots. National Public Radio. December 2, 2023. https://psnet.ahrq.gov/issue/some-doctors-are-ditching-scale-saying-focusing-weight-drives-misdiagnoses Inordinate focus on one element o…