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9941. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60742/psn-pdf
      July 29, 2020 - Doctors and dentists still flooding U.S. with opioid prescriptions. July 29, 2020 Mann B. Doctors and dentists still flooding U.S. with opioid prescriptions. National Public Radio. 2020;July 17. https://psnet.ahrq.gov/issue/doctors-and-dentists-still-flooding-us-opioid-prescriptions Despite efforts to reduce opio…

9942. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865493/psn-pdf
      April 03, 2024 - Implement strategies to prevent persistent medication errors and hazards: 2024. April 3, 2024 ISMP Medication Safety Alert! Acute Care. 2024;29(6):1-4. https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards-2024 Systemic failures can perpetuate unsafe care if a lack of p…

9943. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44260/psn-pdf
      November 06, 2015 - Innovative teaching in situational awareness. November 6, 2015 Gregory A, Hogg G, Ker J. Innovative teaching in situational awareness. Clin Teach. 2015;12(5):331-5. doi:10.1111/tct.12310. https://psnet.ahrq.gov/issue/innovative-teaching-situational-awareness Nontechnical skills contribute to successful teamwork an…

9944. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36576/psn-pdf
      January 14, 2011 - Need for standardized sign-out in the emergency department: a survey of emergency medicine residency and pediatric emergency medicine fellowship program directors. January 14, 2011 Sinha M, Shriki J, Salness R, et al. Need for standardized sign-out in the emergency department: a survey of emergency medicine resid…

9945. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44944/psn-pdf
      July 01, 2016 - Managing and mitigating conflict in healthcare teams: an integrative review. July 1, 2016 Almost J, Wolff AC, Stewart-Pyne A, et al. Managing and mitigating conflict in healthcare teams: an integrative review. J Adv Nurs. 2016;72(7):1490-505. doi:10.1111/jan.12903. https://psnet.ahrq.gov/issue/managing-and-mitigat…

9946. 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…

9947. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50594/psn-pdf
      October 30, 2019 - Pharmacist linkage in care transitions: from academic medical center to community. October 30, 2019 Bloodworth LS, Malinowski SS, Lirette ST, et al. Pharmacist linkage in care transitions: from academic medical center to community. J Am Pharm Assoc . 2019;59(6):896-904. doi:10.1016/j.japh.2019.08.011. https://psne…

9948. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50825/psn-pdf
      January 22, 2020 - Investigation into Detection of Retained Vaginal Swabs and Tampons Following Childbirth. January 22, 2020 Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019. https://psnet.ahrq.gov/issue/investigation-detection-retained-vaginal-swabs-and-tampons-following- childbirth Maternal care during a…

9949. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73477/psn-pdf
      July 07, 2021 - Closing Death’s Door: Legal Innovations to End the Epidemic of Healthcare Harm. July 7, 2021 Saks M, Landsman S. New York, NY: Oxford University Press; 2021.  ISBN: 9780190667986. https://psnet.ahrq.gov/issue/closing-deaths-door-legal-innovations-end-epidemic-healthcare-harm A weave of systemic factors c…

9950. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45756/psn-pdf
      December 21, 2016 - Accidental IV infusion of heparinized irrigation in the OR. December 21, 2016 ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3. https://psnet.ahrq.gov/issue/accidental-iv-infusion-heparinized-irrigation-or Accidental administration of irrigation solutions are a wrong-route error that can re…

9951. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43394/psn-pdf
      July 30, 2014 - With oral chemotherapy, we simply must do better! July 30, 2014 ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4. https://psnet.ahrq.gov/issue/oral-chemotherapy-we-simply-must-do-better To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter …

9952. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45572/psn-pdf
      March 22, 2017 - Ordering interruptions in a tertiary care center: a prospective observational study. March 22, 2017 Dadlez NM, Azzarone G, Sinnett MJ, et al. Ordering Interruptions in a Tertiary Care Center: A Prospective Observational Study. Hosp Pediatr. 2017;7(3):134-139. doi:10.1542/hpeds.2016-0127. https://psnet.ahrq.gov/iss…

9953. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47781/psn-pdf
      February 27, 2019 - Medicine Safety: Take Care. February 27, 2019 Lim R, Semple S, Ellett LK, Roughead L. Canberra, Australia: Pharmaceutical Society of Australia; 2019. https://psnet.ahrq.gov/issue/medicine-safety-take-care Analyzing the evidence on medication errors in Australia, this report estimates the incidence of acute care ad…

9954. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47485/psn-pdf
      January 09, 2019 - System-related and cognitive errors in laboratory medicine. January 9, 2019 Plebani M. System-related and cognitive errors in laboratory medicine. Diagnosis (Berl). 2018;5(4):191- 196. doi:10.1515/dx-2018-0085. https://psnet.ahrq.gov/issue/system-related-and-cognitive-errors-laboratory-medicine Problems managing …

9955. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36664/psn-pdf
      May 27, 2011 - A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions. May 27, 2011 Karnon J, McIntosh A, Dean JE, et al. A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions. Saf Sci. 2006;45(4).…

9956. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46630/psn-pdf
      November 15, 2017 - Patient Safety in the Office-Based Practice Setting. November 15, 2017 Philadelphia, PA: American College of Physicians; 2017. https://psnet.ahrq.gov/issue/patient-safety-office-based-practice-setting Patient safety in the ambulatory setting is gaining traction as a focus for research, intervention, and policy. Th…

9957. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42102/psn-pdf
      April 03, 2013 - Enhancing electronic health record usability in pediatric patient care: a scenario-based approach. April 3, 2013 Patterson ES, Zhang J, Abbott P, et al. Enhancing electronic health record usability in pediatric patient care: a scenario-based approach. Jt Comm J Qual Patient Saf. 2013;39(3):129-135. https://psnet.a…

9958. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38925/psn-pdf
      September 16, 2009 - A literature review of the individual and systems factors that contribute to medication errors in nursing practice. September 16, 2009 Brady A-M, Malone A-M, Fleming S. A literature review of the individual and systems factors that contribute to medication errors in nursing practice. J Nurs Manag. 2009;17(6):679-97…

9959. 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…

9960. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42415/psn-pdf
      July 24, 2013 - Strategies for improving communication in the emergency department: mediums and messages in a noisy environment. July 24, 2013 Welch SJ, Cheung DS, Apker J, et al. Strategies for improving communication in the emergency department: mediums and messages in a noisy environment. Jt Comm J Qual Patient Saf. 2013;39(6)…