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9521. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35348/psn-pdf
      October 26, 2007 - Medical Error. October 26, 2007 National Patient Safety Agency, Medical Defence Union, Medical Protection Society. London, UK: National Patient Safety Agency; 2005. https://psnet.ahrq.gov/issue/medical-error This two-part report focuses on the experience of committing a medical error, along with strategies to red…

9522. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853629/psn-pdf
      September 20, 2023 - Global Knowledge Sharing Platform for Patient Safety. September 20, 2023 World Health Organization. https://psnet.ahrq.gov/issue/global-knowledge-sharing-platform-patient-safety The sharing of best practices is a key component of enabling successful strategy implementation in support of patient safety plans and go…

9523. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40868/psn-pdf
      October 19, 2011 - Simulation to enhance patient safety: why aren't we there yet? October 19, 2011 Aggarwal R, Darzi A. Simulation to enhance patient safety: why aren't we there yet? Chest. 2011;140(4):854-858. doi:10.1378/chest.11-0728. https://psnet.ahrq.gov/issue/simulation-enhance-patient-safety-why-arent-we-there-yet Discussin…

9524. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45026/psn-pdf
      April 19, 2016 - Managing the risks of concurrent surgeries. April 19, 2016 Mello MM, Livingston EH. Managing the Risks of Concurrent Surgeries. JAMA. 2016;315(15):1563-4. doi:10.1001/jama.2016.2305. https://psnet.ahrq.gov/issue/managing-risks-concurrent-surgeries Scheduling overlapping surgeries may improve operating room efficie…

9525. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46408/psn-pdf
      November 29, 2017 - Eliminating vincristine administration events. November 29, 2017 Quick Safety. October 16, 2017;(37):1-3. https://psnet.ahrq.gov/issue/eliminating-vincristine-administration-events Vincristine administration errors can have serious consequences. This newsletter article outlines steps to reduce risks associated wit…

9526. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43086/psn-pdf
      March 26, 2014 - International Comparisons: A Focus on Quality of Care. March 26, 2014 Ottawa, ON: Canadian Institute for Health Information; January 23, 2014. https://psnet.ahrq.gov/issue/international-comparisons-focus-quality-care This report compared the quality of care in Canada with 34 other countries to identify areas in whi…

9527. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42228/psn-pdf
      October 08, 2013 - Cognitive diagnostic error in internal medicine. October 8, 2013 Van den Berge K, Mamede S. Cognitive diagnostic error in internal medicine. Eur J Intern Med. 2013;24(6):525-9. doi:10.1016/j.ejim.2013.03.006. https://psnet.ahrq.gov/issue/cognitive-diagnostic-error-internal-medicine This review discusses how confir…

9528. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61052/psn-pdf
      April 01, 2019 - Inadvertent Administration of an Oral Liquid Medicine into a Vein. April 1, 2019 Farnborough, UK; Healthcare Safety Investigation Branch: April 2019. https://psnet.ahrq.gov/issue/inadvertent-administration-oral-liquid-medicine-vein Wrong route medication administration is a never event. This report examined the co…

9529. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47047/psn-pdf
      June 06, 2018 - MedStar Health Institute for Quality and Safety. June 6, 2018 MedStar Health. 10980 Grantchester Way, Columbia, MD 21044. https://psnet.ahrq.gov/issue/medstar-health-institute-quality-and-safety Health care has recognized the importance of designing systems solutions that reduce risks. Established within MedStar H…

9530. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41931/psn-pdf
      December 19, 2012 - Preventing wrong-site surgery in Minnesota: a 5-year journey. December 19, 2012 Rydrych D, Apold J, Harder K. Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34. https://psnet.ahrq.gov/issue/preventing-wrong-site-surgery-minnesota-5-year-journey Discussing a 5-year effort to report, analyze, and red…

9531. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39807/psn-pdf
      December 29, 2014 - Perspectives in quality: designing the WHO Surgical Safety Checklist. December 29, 2014 Weiser TG, Haynes AB, Lashoher A, et al. Perspectives in quality: designing the WHO Surgical Safety Checklist. Int J Qual Health Care. 2010;22(5):365-70. doi:10.1093/intqhc/mzq039. https://psnet.ahrq.gov/issue/perspectives-qual…

9532. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42358/psn-pdf
      June 12, 2013 - CDC Grand Rounds: preventing unsafe injection practices in the U.S. health-care system. June 12, 2013 Prevention C for DC and. CDC grand rounds: preventing unsafe injection practices in the U.S. health-care system. MMWR Morb Mortal Wkly Rep. 2013;62(21):423-5. https://psnet.ahrq.gov/issue/cdc-grand-rounds-preventi…

9533. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39182/psn-pdf
      May 22, 2019 - ACOG Committee Opinion No. 447: patient safety in obstetrics and gynecology. May 22, 2019 Improvement AC of O and GCC on PS and Q. ACOG Committee Opinion No. 447: Patient safety in obstetrics and gynecology. Obstet Gynecol. 2009;114(6):1424-7. doi:10.1097/AOG.0b013e3181c6f90e. https://psnet.ahrq.gov/issue/acog-com…

9534. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50805/psn-pdf
      January 15, 2020 - Advancing safety with closed-loop communication of test results. January 15, 2020 Quick Safety. December 17, 2019;(52):1-3. https://psnet.ahrq.gov/issue/advancing-safety-closed-loop-communication-test-results Incomplete or delayed test result communication is a known factor in diagnostic error. This article shares…

9535. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846765/psn-pdf
      March 29, 2023 - Addressing Medical Gaslighting to Improve Maternal Health—Together. March 29, 2023 Oregon Patient Safety Commission: 2023. https://psnet.ahrq.gov/issue/addressing-medical-gaslighting-improve-maternal-health-together Gaslighting has been identified as a contributor to maternal mortality and morbidity. This toolkit …

9536. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41053/psn-pdf
      December 30, 2014 - Time to accelerate integration of human factors and ergonomics in patient safety. December 30, 2014 Gurses AP, Ozok A, Pronovost P. Time to accelerate integration of human factors and ergonomics in patient safety. BMJ Qual Saf. 2012;21(4):347-51. doi:10.1136/bmjqs-2011-000421. https://psnet.ahrq.gov/issue/time-acc…

9537. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46334/psn-pdf
      August 09, 2017 - Maternal deaths at MetroWest hospital prompt state probes. August 9, 2017 Kowalczyk L. Boston Globe. July 29, 2017. https://psnet.ahrq.gov/issue/maternal-deaths-metrowest-hospital-prompt-state-probes Maternal death is a sentinel event. This news article reports on two incidents at one hospital that prompted inves…

9538. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37359/psn-pdf
      January 02, 2017 - Case study: preventing surgical complications at Baystate Medical Center. January 2, 2017 Fitzgerald J, Kanter G, Benjamin EM. Case Study: Preventing Surgical Complications at Baystate Medical Center. The Joint Commission Journal on Quality and Patient Safety. 2016;33(11). doi:10.1016/s1553- 7250(07)33076-6. http…

9539. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74259/psn-pdf
      January 19, 2022 - Diagnostic reasoning in cardiovascular medicine. January 19, 2022 Brush JE, Sherbino J, Norman GR. Diagnostic reasoning in cardiovascular medicine. BMJ. 2022;376:e064389. doi:10.1136/bmj-2021-064389. https://psnet.ahrq.gov/issue/diagnostic-reasoning-cardiovascular-medicine Misdiagnosis of heart failure can lead to…

9540. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73872/psn-pdf
      September 22, 2021 - Parenteral nutrition safety. September 22, 2021 Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20. https://psnet.ahrq.gov/issue/parenteral-nutrition-safety Parenteral nutrition (PN) processes contain various steps that are prone to errors resulting in patient harm. This article discusses …