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psnet.ahrq.gov/node/40497/psn-pdf
June 15, 2011 - Are we finally getting serious about medical errors?
June 15, 2011
Burns J.
https://psnet.ahrq.gov/issue/are-we-finally-getting-serious-about-medical-errors
This article explores the challenges to improving patient safety and discusses strategies for reducing
medical errors.
https://psnet.ahrq.gov/issue/are-we-fi…
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psnet.ahrq.gov/node/34905/psn-pdf
February 25, 2009 - On the quest for Six Sigma.
February 25, 2009
Moorman D. On the quest for Six Sigma. Am J Surg. 2005;189(3):253-8.
https://psnet.ahrq.gov/issue/quest-six-sigma
This discussion of patient safety from a surgical perspective highlights issues involving hierarchy, human
factors, and multidisciplinary team training as …
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psnet.ahrq.gov/node/41475/psn-pdf
June 20, 2012 - Behind one hospital's fight against deadly infection.
June 20, 2012
Landro L.
https://psnet.ahrq.gov/issue/behind-one-hospitals-fight-against-deadly-infection
This newspaper article describes how one hospital reduced hospital-acquired infection rates.
https://psnet.ahrq.gov/issue/behind-one-hospitals-fight-against…
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psnet.ahrq.gov/node/40299/psn-pdf
April 16, 2018 - Medication errors in the emergency department: need for
pharmacy involvement?
April 16, 2018
https://psnet.ahrq.gov/issue/medication-errors-emergency-department-need-pharmacy-involvement
This piece reports on the prevalence of medication errors in the emergency department and suggests
expanding pharmacy involvemen…
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psnet.ahrq.gov/node/39589/psn-pdf
February 13, 2018 - Common cause analysis.
February 13, 2018
Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.
https://psnet.ahrq.gov/issue/common-cause-analysis
This article describes how one health care system used a multi-event analysis process to identify
medication errors, implement system-level improvements, a…
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psnet.ahrq.gov/node/41471/psn-pdf
June 20, 2012 - Patients taking their own medications while in the
hospital.
June 20, 2012
PA-PSRS Patient Saf Advis. June 2012;9:50-57.
https://psnet.ahrq.gov/issue/patients-taking-their-own-medications-while-hospital
Discussing errors related to hospital patients' use of personal medications, this newsletter article provi…
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psnet.ahrq.gov/node/37106/psn-pdf
August 15, 2007 - Experts offer smart tips for smart pumps.
August 15, 2007
Gebhart F. Drug Topics. July 23, 2007.
https://psnet.ahrq.gov/issue/experts-offer-smart-tips-smart-pumps
This article describes how robust drug libraries developed for programmable smart pumps can help reduce
medication errors associated with traditional in…
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psnet.ahrq.gov/node/33976/psn-pdf
December 18, 2008 - Medical errors: overcoming the challenges.
December 18, 2008
Kalra J. Medical errors: overcoming the challenges. Clin Biochem. 2004;37(12):1063-71.
https://psnet.ahrq.gov/issue/medical-errors-overcoming-challenges
This commentary introduces several initiatives intended to help reduce medical error, such as developm…
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psnet.ahrq.gov/node/38683/psn-pdf
November 03, 2012 - Errors in Laboratory Medicine and Patient Safety.
November 3, 2012
Plebani M, ed. Clinica Chimica Acta. 2009;404(1):1-86.
https://psnet.ahrq.gov/issue/errors-laboratory-medicine-and-patient-safety
This collection of papers presented at an international conference on laboratory medicine focuses on
efforts to reduce…
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psnet.ahrq.gov/node/39744/psn-pdf
September 13, 2010 - Are you using checklists? Check!
September 13, 2010
McNellis B, AAPA QCC of the. Are you using checklists? Check!. JAAPA. 2010;23(7):24-6, 31.
https://psnet.ahrq.gov/issue/are-you-using-checklists-check
This piece emphasizes how checklists can be effective tools to prevent medical error and reduce
communication fa…
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psnet.ahrq.gov/node/35320/psn-pdf
September 14, 2005 - How business intelligence can improve patient safety.
September 14, 2005
Wanless S, McManaway J. Metaphor Analytics. August 30, 2005.
https://psnet.ahrq.gov/issue/how-business-intelligence-can-improve-patient-safety
This article illustrates how hospitals can use their own administrative and patient data to reduce h…
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psnet.ahrq.gov/node/49793/psn-pdf
May 01, 2017 - Hemolysis Holdup
May 1, 2017
Lehman CM. Hemolysis Holdup. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hemolysis-holdup
The Case
A 72-year-old man with congestive heart failure due to nonischemic cardiomyopathy, stage 3 chronic
kidney disease, atrial fibrillation, and type 2 diabetes mellitus presented t…
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psnet.ahrq.gov/node/33781/psn-pdf
March 01, 2015 - In Conversation With… Brian Jarman, PhD
March 1, 2015
In Conversation With… Brian Jarman, PhD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
Editor's note: Sir Brian Jarman is an emeritus professor at Imperial College School of Medicine and a
past president of the Britis…
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psnet.ahrq.gov/node/42940/psn-pdf
February 12, 2014 - Medical disrespect.
February 12, 2014
Yurkiewicz I. Aeon Magazine. January 29, 2014.
https://psnet.ahrq.gov/issue/medical-disrespect
Disruptive behavior is a well-known and pervasive issue in health care. Describing disrespectful behaviors
that clinicians face, such as sarcasm and intimidation, this magazine artic…
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psnet.ahrq.gov/node/38917/psn-pdf
September 06, 2013 - Health Care–Associated Infections.
September 6, 2013
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/health-care-associated-infections
For health care providers and consumers, this Web site features information, tools, and resources on
health care–associated infections (HAIs). AHRQ-funded …
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psnet.ahrq.gov/node/41919/psn-pdf
December 12, 2012 - The best medicine for fixing the modern hospital.
December 12, 2012
https://psnet.ahrq.gov/issue/best-medicine-fixing-modern-hospital
This news article highlights how hospital design can help reduce infection rates, shorten length of stay, and
improve patient safety.
https://psnet.ahrq.gov/issue/best-medicine-fixi…
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psnet.ahrq.gov/node/38971/psn-pdf
June 10, 2018 - How has the current economy affected patient safety?
June 10, 2018
ISMP Medication Safety Alert! Acute Care Edition. September 10, 2009;14:1-2.
https://psnet.ahrq.gov/issue/how-has-current-economy-affected-patient-safety
This piece describes how reduced resources could affect patient safety and quality work in hosp…
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psnet.ahrq.gov/node/40077/psn-pdf
July 10, 2012 - Improvement Cymru.
July 10, 2012
NHS Wales.
https://psnet.ahrq.gov/issue/improvement-cymru
This national program draws from other large collaborative efforts to engage health care organizations
across Wales in reducing preventable harm. It was rebranded from the 1000 Lives campaign in 2018.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/39762/psn-pdf
October 01, 2010 - Dennis Quaid's quest.
August 18, 2010
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
https://psnet.ahrq.gov/issue/dennis-quaids-quest
This article highlights how a medication error inspired Dennis Quaid to promote patient safety and
chronicles his efforts to reduce harm in health care.
https:/…
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psnet.ahrq.gov/node/40481/psn-pdf
June 20, 2011 - Medication errors—new approaches to prevention.
June 20, 2011
Merry A, Anderson BJ. Medication errors--new approaches to prevention. Paediatr Anaesth.
2011;21(7):743-53. doi:10.1111/j.1460-9592.2011.03589.x.
https://psnet.ahrq.gov/issue/medication-errors-new-approaches-prevention
This review discusses evidence-bas…