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4261. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39962/psn-pdf
      September 24, 2016 - Interruptions and medication errors: part I. September 24, 2016 Flanders S, Clark AP. Interruptions and medication errors: part I. Clin Nurse Spec. 2010;24(6):281-5. doi:10.1097/NUR.0b013e3181faf78b. https://psnet.ahrq.gov/issue/interruptions-and-medication-errors-part-i This commentary discusses preventable medic…

4262. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38919/psn-pdf
      January 28, 2011 - Setting priorities for patient safety: ethics, accountability, and public engagement. January 28, 2011 Pronovost P, Faden RR. Setting priorities for patient safety: ethics, accountability, and public engagement. JAMA. 2009;302(8):890-1. doi:10.1001/jama.2009.1177. https://psnet.ahrq.gov/issue/setting-priorities-pa…

4263. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39652/psn-pdf
      June 30, 2010 - Aftercare tips for patients checking out of the hospital. June 30, 2010 Alderman L. New York Times. June 18, 2010;B6. https://psnet.ahrq.gov/issue/aftercare-tips-patients-checking-out-hospital This news piece highlights efforts to improve discharge planning, enhance the safety of care transitions, and reduce readm…

4264. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35246/psn-pdf
      July 11, 2007 - Treatment errors in healthcare: a safety climate approach. July 11, 2007 Naveh E, Katz-Navon T, Stern Z. Treatment errors in healthcare: a safety climate approach. . Manage Sci. 2005;51(6):948-960. doi:10.1287/mnsc.1050.0372. https://psnet.ahrq.gov/issue/treatment-errors-healthcare-safety-climate-approach The auth…

4265. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35353/psn-pdf
      July 16, 2009 - Best-practice protocols: preventing adverse drug events. July 16, 2009 Weir VL. Best-practice protocols: preventing adverse drug events. Nurs Manage. 2005;36(9):24-30. https://psnet.ahrq.gov/issue/best-practice-protocols-preventing-adverse-drug-events This article reports on one hospital's use of failure modes and …

4266. Syringe Swap During Regional Block: A Case of Medication Error and Recovery | PSNet
      psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
      July 22, 2020 - communication, and procedure implementation can contribute positively to support an education program that reduces

4267. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35891/psn-pdf
      May 03, 2006 - Costs and Benefits of Health Information Technology. May 3, 2006 Shekelle PG, Morton SC, Keeler EB. Rockville, MD: Agency for Healthcare Research and Quality; April 2006. AHRQ Publication No. 06-E006. https://psnet.ahrq.gov/issue/costs-and-benefits-health-information-technology The authors reviewed the literature …

4268. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35952/psn-pdf
      August 02, 2010 - Manage staff fatigue to improve patient safety. August 2, 2010 Spath P. Manage staff fatigue to improve patient safety. Part 2 of 2. Hospital peer review. 2006;31(5):70-2. https://psnet.ahrq.gov/issue/manage-staff-fatigue-improve-patient-safety The author discusses three steps for reducing staff fatigue. Part I of …

4269. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36948/psn-pdf
      September 09, 2011 - Errors in a stat laboratory: changes in type and frequency since 1996. September 9, 2011 Carraro P, Plebani M. Errors in a stat laboratory: types and frequencies 10 years later. Clin Chem. 2007;53(7):1338-42. https://psnet.ahrq.gov/issue/errors-stat-laboratory-changes-type-and-frequency-1996 The investigators con…

4270. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42596/psn-pdf
      October 23, 2013 - Diagnostic Errors and Strategies to Minimize Them. October 23, 2013 Cutrer WB, Sullivan WM, Fleming AE, et al. Curr Probl Pediatr Adolesc Health Care. 2013;43:225-257.   https://psnet.ahrq.gov/issue/diagnostic-errors-and-strategies-minimize-them Articles in this special issue cover diagnostic errors, includin…

4271. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36533/psn-pdf
      May 27, 2011 - Effect of computerisation on the quality and safety of chemotherapy prescription. May 27, 2011 Voeffray M, Pannatier A, Stupp R, et al. Effect of computerisation on the quality and safety of chemotherapy prescription. Qual Saf Health Care. 2006;15(6):418-21. https://psnet.ahrq.gov/issue/effect-computerisation-qual…

4272. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39484/psn-pdf
      April 28, 2010 - Surgical fires, a clear and present danger. April 28, 2010 Yardley IE, Donaldson LJ. Surgical fires, a clear and present danger. Surgeon. 2010;8(2):87-92. doi:10.1016/j.surge.2010.01.005. https://psnet.ahrq.gov/issue/surgical-fires-clear-and-present-danger This article reviews the literature on surgical fires and …

4273. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40937/psn-pdf
      November 16, 2011 - AHRQ Projects to Prevent Healthcare-Associated Infections, Fiscal Year 2011. November 16, 2011 Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 09- P013-4-E. https://psnet.ahrq.gov/issue/ahrq-projects-prevent-healthcare-associated-infections-fiscal-year-2011 This annou…

4274. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36798/psn-pdf
      March 09, 2009 - Organizational culture, critical success factors, and the reduction of hospital errors. March 9, 2009 Stock GN, McFadden KL, Gowen CR. Organizational culture, critical success factors, and the reduction of hospital errors. Int J Prod Econ. 2006;106(2). doi:10.1016/j.ijpe.2006.07.005. https://psnet.ahrq.gov/issue/o…

4275. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60216/psn-pdf
      April 08, 2020 - The Diagnosis of Ectopic Pregnancy. April 8, 2020 Farnborough, UK:  Healthcare Safety Investigation Branch; March 2020. https://psnet.ahrq.gov/issue/diagnosis-ectopic-pregnancy Missed or delayed diagnosis in maternal care can result in serious harm to both the mother and the child. This report analyzes a dela…

4276. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34925/psn-pdf
      February 27, 2009 - Medication errors and professional practice of registered nurses. February 27, 2009 Deans C. Medication errors and professional practice of registered nurses. Collegian. 2005;12(1):29-33. https://psnet.ahrq.gov/issue/medication-errors-and-professional-practice-registered-nurses This Australian study identified and…

4277. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34002/psn-pdf
      March 17, 2011 - Utah DoH Patient Safety Initiatives. March 17, 2011 Center for Health Data, Utah Department of Health, PO Box 144004, Salt Lake City, UT 84114. https://psnet.ahrq.gov/issue/utah-doh-patient-safety-initiatives Utah established a number of collaborative initiatives to understand the nature and occurrence of adverse …

4278. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38709/psn-pdf
      June 17, 2009 - Enteral feeding misconnections: an update. June 17, 2009 Guenter P, Hicks RW, Simmons D. Enteral feeding misconnections: an update. Nutr Clin Pract. 2009;24(3):325-34. doi:10.1177/0884533609335174. https://psnet.ahrq.gov/issue/enteral-feeding-misconnections-update This review surveys information on enteral nutriti…

4279. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50601/psn-pdf
      October 09, 2022 - Medication Safety: Advancing the Development of Improvement Strategies and Tools (R18). October 9, 2022  Rockville, MD: Agency for Healthcare Research and Quality; September 28, 2022. PA- 20-028. https://psnet.ahrq.gov/issue/medication-safety-advancing-development-improvement Medication errors are …

4280. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36793/psn-pdf
      August 26, 2011 - Patient safety in Taiwan: a survey on orthopedic surgeons. August 26, 2011 Yang C-T, Chen H-H, Hou S-M. Patient safety in Taiwan: a survey on orthopedic surgeons. J Formos Med Assoc. 2007;106(3):212-6. https://psnet.ahrq.gov/issue/patient-safety-taiwan-survey-orthopedic-surgeons The researchers surveyed Taiwanese…