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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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 …
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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 …
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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:/…
  20. Psn-Pdf (pdf file)

    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…

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