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9781. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42218/psn-pdf
      June 10, 2018 - Your high-alert medication list—relatively useless without associated risk-reduction strategies. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. April 4, 2013;18:1-5. https://psnet.ahrq.gov/issue/your-high-alert-medication-list-relatively-useless-without-associated-risk- reduction This newsletter …

9782. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44939/psn-pdf
      March 09, 2016 - Listening for What Matters: Avoiding Contextual Errors in Health Care. March 9, 2016 Weiner SJ, Schwartz A. New York, NY: Oxford University Press; 2016. ISBN: 9780190228996. https://psnet.ahrq.gov/issue/listening-what-matters-avoiding-contextual-errors-health-care This book discusses how physicians can reduce cont…

9783. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837798/psn-pdf
      August 10, 2022 - An evolution of reporting: identifying the missing link. August 10, 2022 Harsini S, Tofighi S, Eibschutz L, et al. An evolution of reporting: identifying the missing link. Diagnostics (Basel). 2022;12(7):1761. doi:10.3390/diagnostics12071761. https://psnet.ahrq.gov/issue/evolution-reporting-identifying-missing-link…

9784. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837002/psn-pdf
      April 27, 2022 - Burnout in Nursing: Causes, Management, and Future Directions. April 27, 2022 Zangaro GA, Dulko D, Sullivan D, eds. Nurs Clin North Am. 2022;57(1):1-170.  https://psnet.ahrq.gov/issue/burnout-nursing-causes-management-and-future-directions Clinician burnout is a pervasive problem and can threaten patient safe…

9785. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38686/psn-pdf
      May 07, 2018 - Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups? May 7, 2018 ISMP Medication Safety Alert! Acute Care Edition. May 21, 2009;14:1-3. https://psnet.ahrq.gov/issue/survey-lasa-drug-name-pairs-who-knows-whats-your-list-and-best-ways- prevent-mix-ups This article shar…

9786. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39552/psn-pdf
      May 26, 2010 - Expanding what we know about off-peak mortality in hospitals. May 26, 2010 Hamilton P, Mathur S, Gemeinhardt G, et al. Expanding what we know about off-peak mortality in hospitals. J Nurs Adm. 2010;40(3):124-8. doi:10.1097/NNA.0b013e3181d0426e. https://psnet.ahrq.gov/issue/expanding-what-we-know-about-peak-mortali…

9787. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41598/psn-pdf
      August 15, 2012 - Obstetrician/gynecologist hospitalists: can we improve safety and outcomes for patients and hospitals and improve lifestyle for physicians? August 15, 2012 Olson R, Garite TJ, Fishman A, et al. Obstetrician/gynecologist hospitalists: can we improve safety and outcomes for patients and hospitals and improve lifesty…

9788. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851451/psn-pdf
      July 19, 2023 - Issues and complexities in safety culture assessment in healthcare. July 19, 2023 Ellis LA, Falkland E, Hibbert P, et al. Issues and complexities in safety culture assessment in healthcare. Front Public Health. 2023;11:1217542. doi:10.3389/fpubh.2023.1217542. https://psnet.ahrq.gov/issue/issues-and-complexities-sa…

9789. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45835/psn-pdf
      February 01, 2017 - Deploying and measuring a risk and patient safety program. February 1, 2017 Orel H, McGroarty M, Marchegiani H. Deploying and measuring a risk and patient safety program. J Healthc Risk Manag. 2017;36(3):26-33. doi:10.1002/jhrm.21266. https://psnet.ahrq.gov/issue/deploying-and-measuring-risk-and-patient-safety-pro…

9790. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866696/psn-pdf
      September 11, 2024 - The Impact of Complications on Surgeons. September 11, 2024 The Impact of Complications on Surgeons. Modi PK, Singer EA, eds. Urol Oncol. 2024;42(10):295-320. doi:10.1016/j.urolonc.2024.05.016. https://psnet.ahrq.gov/issue/impact-complications-surgeons Complications and medical errors can result in psychological d…

9791. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42902/psn-pdf
      January 29, 2014 - Improving Patient Safety Through Teamwork and Team Training. January 29, 2014 Salas E, Frush K, eds. Oxford, UK: Oxford University Press; 2013. ISBN: 9780195399097. https://psnet.ahrq.gov/issue/improving-patient-safety-through-teamwork-and-team-training Health care has been recently been directed toward focusing o…

9792. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39254/psn-pdf
      January 27, 2010 - Practical challenges of introducing WHO surgical checklist: UK pilot experience. January 27, 2010 Vats A, Vincent CA, Nagpal K, et al. Practical challenges of introducing WHO surgical checklist: UK pilot experience. BMJ. 2010;340(jan13 2). doi:10.1136/bmj.b5433. https://psnet.ahrq.gov/issue/practical-challenges-in…

9793. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47696/psn-pdf
      February 22, 2019 - Operating room fires. February 22, 2019 Jones TS, Black IH, Robinson TN, et al. Operating Room Fires. Anesthesiology. 2019;130(3):492-501. doi:10.1097/ALN.0000000000002598. https://psnet.ahrq.gov/issue/operating-room-fires Surgical fires, though uncommon, can result in serious harm. This review highlights three co…

9794. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46875/psn-pdf
      March 07, 2018 - Improving medication-related clinical decision support. March 7, 2018 Tolley CL, Slight SP, Husband AK, et al. Improving medication-related clinical decision support. Am J Health Syst Pharm. 2018;75(4):239-246. doi:10.2146/ajhp160830. https://psnet.ahrq.gov/issue/improving-medication-related-clinical-decision-suppo…

9795. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34048/psn-pdf
      May 27, 2011 - Computerized physician order entry: helpful or harmful? May 27, 2011 Berger RG, Kichak JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc. 2004;11(2):100-3. https://psnet.ahrq.gov/issue/computerized-physician-order-entry-helpful-or-harmful The authors critically review the published …

9796. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841490/psn-pdf
      December 14, 2022 - Prevent administration of ear drops into the eyes. December 14, 2022 ISMP Medication Safety Alert!: Acute Care Edition. December 1, 2022;27(24):1-3. https://psnet.ahrq.gov/issue/prevent-administration-ear-drops-eyes Look-alike medications are vulnerable to wrong route and other use errors. This article examines the…

9797. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44296/psn-pdf
      April 08, 2018 - Checklists to prevent diagnostic errors: a pilot randomized controlled trial. April 8, 2018 Ely JW, Graber MA. Checklists to prevent diagnostic errors: a pilot randomized controlled trial. Diagnosis (Berl). 2015;2(3):163-169. doi:10.1515/dx-2015-0008. https://psnet.ahrq.gov/issue/checklists-prevent-diagnostic-erro…

9798. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46593/psn-pdf
      November 08, 2017 - Unreadable barcodes and multiple barcodes on packages can lead to errors. November 8, 2017 ISMP Medication Safety Alert! Acute care edition. October 19, 2017;22:1-3. https://psnet.ahrq.gov/issue/unreadable-barcodes-and-multiple-barcodes-packages-can-lead-errors Barcodes can both enhance and degrade the medication …

9799. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38213/psn-pdf
      November 12, 2008 - AHRQ announces interest in research on diagnostic errors in ambulatory care settings. November 12, 2008 Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 25, 2007. Publication No. NOT-HS-08-002. https://psnet.ahrq.gov/issue/ahrq-announces-interest-research-diagnostic-error…

9800. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43183/psn-pdf
      May 14, 2014 - Physician: 'I almost killed a patient' because of an advance directive. May 14, 2014 Betbeze P. HealthLeaders Media. May 2, 2014. https://psnet.ahrq.gov/issue/physician-i-almost-killed-patient-because-advance-directive Reporting on how misinterpretation of advance directives and living wills can detract from patie…