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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73253/psn-pdf
    May 12, 2021 - Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations. May 12, 2021 ISMP Medication Safety Alert! Acute Care Edition. April 22, 2021.26(8):1-5. https://psnet.ahrq.gov/issue/any-new-process-poses-risk-errors-learning-4-months-coronavirus-disease- 2019-c…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39860/psn-pdf
    September 01, 2017 - Interventions to improve hand hygiene compliance in patient care. September 1, 2017 Gould DJ, Moralejo D, Drey N, et al. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev. 2017;9(9):CD005186. doi:10.1002/14651858.cd005186.pub4. https://psnet.ahrq.gov/issue/interventions-i…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44172/psn-pdf
    September 28, 2016 - Preventing high-alert medication errors in hospital patients. September 28, 2016 Anderson P, Townsend T. Am Nurse Today. May 2015;10:18-23. https://psnet.ahrq.gov/issue/preventing-high-alert-medication-errors-hospital-patients High-alert medications have the potential to cause serious patient harm. This article fo…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837206/psn-pdf
    May 25, 2022 - Automated dispensing cabinet overrides-an evaluation of necessity in a pediatric emergency department. May 25, 2022 Paterson EP, Manning KB, Schmidt MD, et al. Automated dispensing cabinet overrides-an evaluation of necessity in a pediatric emergency department. J Emerg Nurs. 2022;48(3):319-327. doi:10.1016/j.jen.…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851067/psn-pdf
    June 28, 2023 - Assessing medication safety in settings not designated solely for pediatric patients. June 28, 2023 ISMP Medication Safety Alert! Acute care edition. June 15, 2023;28(12);1-5. https://psnet.ahrq.gov/issue/assessing-medication-safety-settings-not-designated-solely-pediatric-patients Pediatric patients are at increa…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841155/psn-pdf
    February 02, 2020 - Understanding unwarranted variation in clinical practice: a focus on network effects, reflective medicine and learning health systems. February 2, 2020 Atsma F, Elwyn G, Westert GP. Understanding unwarranted variation in clinical practice: a focus on network effects, reflective medicine and learning health systems…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43606/psn-pdf
    October 15, 2014 - Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology. October 15, 2014 Franklin GM, Neurology AA of. Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology. Neurology. 2014;83(14):1277-84. doi:10.1212/WNL.0000000000000839. https://psnet.ahrq.g…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836758/psn-pdf
    March 16, 2022 - Internet of things in healthcare for patient safety: an empirical study. March 16, 2022 Yesmin T, Carter MW, Gladman AS. Internet of things in healthcare for patient safety: an empirical study. BMC Health Serv Res. 2022;22(1):278. doi:10.1186/s12913-022-07620-3. https://psnet.ahrq.gov/issue/internet-things-healthc…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860733/psn-pdf
    January 17, 2024 - Staff warned about the lack of psychiatric care at a VA clinic. They couldn’t prevent tragedy. January 17, 2024 McGrory K, Bedi N. ProPublica, January 6, 2024. https://psnet.ahrq.gov/issue/staff-warned-about-lack-psychiatric-care-va-clinic-they-couldnt-prevent-tragedy Stories of mental health system failure provid…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50904/psn-pdf
    February 19, 2020 - The harms of promoting 'Zero Harm'. February 19, 2020 Thomas EJ. The harms of promoting ‘Zero Harm’. BMJ Qual Saf. 2019;29(1):4-6. doi:10.1136/bmjqs-2019- 009703. https://psnet.ahrq.gov/issue/harms-promoting-zero-harm Achieving “zero harm” has been advocated as a patient safety goal. This editorial proposes that t…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45331/psn-pdf
    August 03, 2016 - Health information technologies: from hazardous to the dark side. August 3, 2016 Saunders C, Rutkowski AF, Pluyter J, et al. Health information technologies: From hazardous to the dark side. J Assoc Inf Sci Technol. 2016;67(7). doi:10.1002/asi.23671. https://psnet.ahrq.gov/issue/health-information-technologies-haz…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43986/psn-pdf
    September 26, 2016 - The effect of a safe zone on nurse interruptions, distractions, and medication administration errors. September 26, 2016 Yoder M, Schadewald D, Dietrich K. The effect of a safe zone on nurse interruptions, distractions, and medication administration errors. J Infus Nurs. 2015;38(2):140-51. doi:10.1097/NAN.000000000…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44317/psn-pdf
    August 19, 2015 - Use of in-situ simulation to investigate latent safety threats prior to opening a new emergency department. August 19, 2015 Medwid K, Smith SW, Gang M. Use of in-situ simulation to investigate latent safety threats prior to opening a new emergency department. Safety Sci. 2015;77:19-24. doi:10.1016/j.ssci.2015.03.01…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50829/psn-pdf
    January 22, 2020 - How one medical checkup can snowball into a ‘cascade’ of tests, causing more harm than good. January 22, 2020 Ganguli I. Washington Post. January 5, 2020. https://psnet.ahrq.gov/issue/how-one-medical-checkup-can-snowball-cascade-tests-causing-more-harm- good Overdiagnosis and uncertainty can result in a range of …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50744/psn-pdf
    December 18, 2019 - EMS crews brought patients to the hospital with misplaced breathing tubes. None of them survived December 18, 2019 Arditi L. Peoples Public Radio. December 3, 2019. https://psnet.ahrq.gov/issue/ems-crews-brought-patients-hospital-misplaced-breathing-tubes-none-them- survived Emergency medical services are often p…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837340/psn-pdf
    June 08, 2022 - Wellbeing, burnout, and safe practice among healthcare professionals: predictive influences of mindfulness, values, and self-compassion. June 8, 2022 Prudenzi A, D. Graham C, Flaxman PE, et al. Wellbeing, burnout, and safe practice among healthcare professionals: predictive influences of mindfulness, values, and s…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60286/psn-pdf
    April 29, 2020 - With Covid-19 delaying routine care, chronic disease startups brace for a slew of complications. April 29, 2020 Brodwin E. STAT. April 14, 2020. https://psnet.ahrq.gov/issue/covid-19-delaying-routine-care-chronic-disease-startups-brace-slew- complications Patients with cancer and other chronic disorder treatment …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42673/psn-pdf
    October 30, 2013 - Clinical evaluation of the ADE scorecards as a decision support tool for adverse drug event analysis and medication safety management. October 30, 2013 Hackl WO, Ammenwerth E, Marcilly R, et al. Clinical evaluation of the ADE scorecards as a decision support tool for adverse drug event analysis and medication safe…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43105/psn-pdf
    April 02, 2014 - Application of surgical safety standards to robotic surgery: five principles of ethics for nonmaleficence. April 2, 2014 Larson JA, Johnson MH, Bhayani SB. Application of surgical safety standards to robotic surgery: five principles of ethics for nonmaleficence. J Am Coll Surg. 2014;218(2):290-3. doi:10.1016/j.jam…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72584/psn-pdf
    December 16, 2020 - Hidden medication loss when using a primary administration set for small-volume intermittent infusions. December 16, 2020 ISMP Medication Safety Alert! Acute care edition. December 3, 2020;25(24). https://psnet.ahrq.gov/issue/hidden-medication-loss-when-using-primary-administration-set-small-volume- intermittent …