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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42364/psn-pdf
    September 18, 2013 - The pursuit of better diagnostic performance: a human factors perspective. September 18, 2013 Henriksen K, Brady J. The pursuit of better diagnostic performance: a human factors perspective. BMJ Qual Saf. 2013;22(Suppl 2):ii1-ii5. doi:10.1136/bmjqs-2013-001827. https://psnet.ahrq.gov/issue/pursuit-better-diagnosti…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36431/psn-pdf
    March 28, 2011 - Using the internet to deliver education on drug safety. March 28, 2011 Franklin B, O'Grady K, Parr J, et al. Using the internet to deliver education on drug safety. Qual Saf Health Care. 2006;15(5):329-33. https://psnet.ahrq.gov/issue/using-internet-deliver-education-drug-safety The project team implemented a web-…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43318/psn-pdf
    July 02, 2014 - Sign up to Safety. July 2, 2014 National Health Service. https://psnet.ahrq.gov/issue/sign-safety Through a coordinated effort to set goals and devise plans to improve safety in hospitals, the Sign up to Safety campaign aims to prevent 6000 patient deaths in the next 3 years in National Health Service facilities.…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40696/psn-pdf
    December 01, 2011 - Rapid response systems: a prospective study of response times. December 1, 2011 Adelstein B-A, Piza MA, Nayyar V, et al. Rapid response systems: a prospective study of response times. J Crit Care. 2011;26(6):635.e11-8. doi:10.1016/j.jcrc.2011.03.013. https://psnet.ahrq.gov/issue/rapid-response-systems-prospective-…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38341/psn-pdf
    April 02, 2009 - CPOE: it don't come easy. April 2, 2009 Anderson HJ. CPOE: it don't come easy. Health Data Manag. 2009;17(1):18-20, 22, 24 passim. https://psnet.ahrq.gov/issue/cpoe-it-dont-come-easy Although shifting from paper-based or verbal orders to computerized physician order entry (CPOE) systems could reduce medical errors…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40568/psn-pdf
    June 29, 2011 - Tubing misconnections: normalization of deviance. June 29, 2011 Simmons D, Symes L, Guenter P, et al. Tubing misconnections: normalization of deviance. Nutr Clin Pract. 2011;26(3):286-293. doi:10.1177/0884533611406134. https://psnet.ahrq.gov/issue/tubing-misconnections-normalization-deviance Analyzing published ca…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40903/psn-pdf
    March 08, 2015 - Does your patient really understand? March 8, 2015 Huff C. Does your patient really understand? Hospitals & health networks. 2011;85(10):34-5, 37-8, 2. https://psnet.ahrq.gov/issue/does-your-patient-really-understand This article discusses health literacy and describes an initiative to reduce gaps in understanding …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44436/psn-pdf
    October 30, 2017 - Overreaction. October 30, 2017 Shell ER. Overreaction. Scientific American. 2015;313(5):28-9. https://psnet.ahrq.gov/issue/overreaction Reporting on how test inaccuracies can lead to misdiagnosis of food allergies in children and the potential consequences, this magazine article describes a diagnostic tool to dete…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39465/psn-pdf
    May 08, 2018 - Latest heparin fatality speaks loudly—what have you done to stop the bleeding? May 8, 2018 ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3. https://psnet.ahrq.gov/issue/latest-heparin-fatality-speaks-loudly-what-have-you-done-stop-bleeding Detailing a recent lethal overdose of heparin, this …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42344/psn-pdf
    September 24, 2016 - Strategies for preventing distractions and interruptions in the OR. September 24, 2016 Clark GJ. Strategies for preventing distractions and interruptions in the OR. AORN J. 2013;97(6):702-707. doi:10.1016/j.aorn.2013.01.018. https://psnet.ahrq.gov/issue/strategies-preventing-distractions-and-interruptions-or Dist…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37749/psn-pdf
    July 16, 2018 - Practice advisory for the prevention and management of operating room fires.  July 16, 2018 Fires AS of ATF on OR, Caplan RA, Barker SJ, et al. Practice advisory for the prevention and management of operating room fires. Anesthesiology. 2008;108(5):786-801; quiz 971-2. doi:10.1097/01.anes.0000299343.87119.a9. htt…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40668/psn-pdf
    March 04, 2015 - Body CT: technical advances for improving safety. March 4, 2015 Marin D, Nelson RC, Rubin GD, et al. Body CT: technical advances for improving safety. AJR Am J Roentgenol. 2011;197(1):33-41. doi:10.2214/AJR.11.6755. https://psnet.ahrq.gov/issue/body-ct-technical-advances-improving-safety This article explores risk…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35382/psn-pdf
    October 05, 2005 - Rx for a better prescription. Hospital bans doctors from using confusing medical abbreviations. October 5, 2005 Hall J. Fredericksburg Times. September 25, 2005 https://psnet.ahrq.gov/issue/rx-better-prescription-hospital-bans-doctors-using-confusing-medical- abbreviations This article presents one hospital’s pro…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46466/psn-pdf
    July 11, 2018 - Distinct newborn identification requirement. July 11, 2018 R3 Report. June 25, 2018;7:1-2. https://psnet.ahrq.gov/issue/distinct-newborn-identification-requirement Neonatal patients are at risk for misidentification due to communication challenges and lack of distinguishable features. This report highlights new Jo…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42830/psn-pdf
    December 18, 2013 - How to Identify and Address Unsafe Conditions Associated With Health IT. December 18, 2013 Wallace C, Zimmer KP, Possanza L, Giannini R, Solomon R. Washington, DC: Office of the National Coordinator for Health Information Technology; November 15, 2013. https://psnet.ahrq.gov/issue/how-identify-and-address-unsafe-c…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73431/psn-pdf
    June 23, 2021 - Drive to Deprescribe. June 23, 2021 The Society for Post-Acute and Long-Term Care Medicine. https://psnet.ahrq.gov/issue/drive-deprescribe Polypharmacy is a known challenge to patient safety. This collective program encourages long-term care organizations, physicians, and pharmacists to take part in a learning net…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42332/psn-pdf
    June 12, 2013 - Quality improvement through implementation of discharge order reconciliation. June 12, 2013 Lu Y, Clifford P, Bjorneby A, et al. Quality improvement through implementation of discharge order reconciliation. Am J Health Syst Pharm. 2013;70(9):815-20. doi:10.2146/ajhp120050. https://psnet.ahrq.gov/issue/quality-impr…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42753/psn-pdf
    November 20, 2013 - Dealing with a medical mistake: should physicians apologize to patients? November 20, 2013 Tabler NG Jr. https://psnet.ahrq.gov/issue/dealing-medical-mistake-should-physicians-apologize-patients This article discusses how apologies address patients' needs when a medical mistake has occurred and how such disclosur…
  19. digital.ahrq.gov/ahrq-funded-projects/integrating-contextual-factors-clinical-decision-support-reduce-contextual/citation/contextualizing
    January 01, 2023 - Contextualizing care: An essential and measurable clinical competency. Citation Weiner SJ. Contextualizing care: An essential and measurable clinical competency. Patient Educ Couns. 2022 Mar;105(3):594-598. doi: 10.1016/j.pec.2021.06.016. Epub 2021 Jun 15. PMID: 34158194. Link https://pubmed.n…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47556/psn-pdf
    November 28, 2018 - Improving Diagnosis. November 28, 2018 Deutsch E, ed. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):1-70. https://psnet.ahrq.gov/issue/improving-diagnosis This special issue raises awareness of challenges to reducing diagnostic error. Articles discuss insights from experts about how to improve diagnosis, t…