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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44091/psn-pdf
    January 04, 2019 - Isolation precautions for visitors. January 4, 2019 Munoz-Price LS, Banach DB, Bearman G, et al. Isolation Precautions for Visitors. Infect Control Hosp Epidemiol. 2015;36(7):747-758. doi:10.1017/ice.2015.67. https://psnet.ahrq.gov/issue/isolation-precautions-visitors This expert guidance provides recommendations …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840164/psn-pdf
    November 16, 2022 - Medical error and vulnerable communities. November 16, 2022 Jean-Pierre P. Boston U Law Rev. 2022; 102(1):327-392. https://psnet.ahrq.gov/issue/medical-error-and-vulnerable-communities Bias and discrimination are receiving overdue attention as primary barriers to patient safety. This article discusses medical erro…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837858/psn-pdf
    August 17, 2022 - Tackling implicit bias in health care. August 17, 2022 Sabin JA. Tackling implicit bias in health care. N Engl J Med. 2022;387(2):105-107. doi:10.1056/nejmp2201180. https://psnet.ahrq.gov/issue/tackling-implicit-bias-health-care Implicit bias in clinicians can result in diagnostic errors and poor patient outcomes.…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47390/psn-pdf
    September 19, 2018 - Antimicrobial Stewardship. September 19, 2018 Cunha CB, ed. Med Clin North Am. 2018;102(5):797-976. https://psnet.ahrq.gov/issue/antimicrobial-stewardship Antimicrobial stewardship programs are a key strategy to reduce overprescribing of antibiotics in hospitals. This special issue explores approaches to engage a …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73926/psn-pdf
    October 06, 2021 - Good for You, Good for Us, Good for Everybody. October 6, 2021 Ridge K. London, England: Crown Copyright; 2021. September 22, 2021. https://psnet.ahrq.gov/issue/good-you-good-us-good-everybody Overprescribing has attained prominence as a safety issue due to the current opioid epidemic, but it has long reduced medi…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47696/psn-pdf
    February 22, 2019 - Operating room fires. February 22, 2019 Jones TS, Black IH, Robinson TN, et al. Operating Room Fires. Anesthesiology. 2019;130(3):492-501. doi:10.1097/ALN.0000000000002598. https://psnet.ahrq.gov/issue/operating-room-fires Surgical fires, though uncommon, can result in serious harm. This review highlights three co…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38541/psn-pdf
    May 21, 2009 - The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level: analysis of administrative data. May 21, 2009 Van den Heede K, Lesaffre E, Diya L, et al. The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level: analysis of administr…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50577/psn-pdf
    October 23, 2019 - Medicare's Oversight of Ambulatory Surgery Centers Report. October 23, 2019 Washington, DC: Office of the Inspector General; September 2019. Report No. OEI-01-15-00400. https://psnet.ahrq.gov/issue/medicares-oversight-ambulatory-surgery-centers-report Ambulatory surgery centers (ASC) play an increasing role in com…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42974/psn-pdf
    September 07, 2016 - Chemotherapy drug shortages in pediatric oncology: a consensus statement. September 7, 2016 Decamp M, Joffe S, Fernandez C, et al. Chemotherapy drug shortages in pediatric oncology: a consensus statement. Pediatrics. 2014;133(3):e716-24. doi:10.1542/peds.2013-2946. https://psnet.ahrq.gov/issue/chemotherapy-drug-sh…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34048/psn-pdf
    May 27, 2011 - Computerized physician order entry: helpful or harmful? May 27, 2011 Berger RG, Kichak JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc. 2004;11(2):100-3. https://psnet.ahrq.gov/issue/computerized-physician-order-entry-helpful-or-harmful The authors critically review the published …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40043/psn-pdf
    March 03, 2011 - Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit. March 3, 2011 McCulloch P, Kreckler S, New S, et al. Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit. BMJ. 2010;341:c5469. doi:10.1136/bmj.c5469. https://psne…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841490/psn-pdf
    December 14, 2022 - Prevent administration of ear drops into the eyes. December 14, 2022 ISMP Medication Safety Alert!: Acute Care Edition. December 1, 2022;27(24):1-3. https://psnet.ahrq.gov/issue/prevent-administration-ear-drops-eyes Look-alike medications are vulnerable to wrong route and other use errors. This article examines the…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45747/psn-pdf
    December 21, 2016 - Implementing No Interruption Zones in the perioperative environment. December 21, 2016 Wright I. Implementing No Interruption Zones in the Perioperative Environment. AORN J. 2016;104(6):536- 540. doi:10.1016/j.aorn.2016.09.018. https://psnet.ahrq.gov/issue/implementing-no-interruption-zones-perioperative-environme…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72688/psn-pdf
    October 06, 2022 - Request for proposals for clinical quality measures to improve diagnosis. October 6, 2022 Palo Alto CA; Gordon and Betty Moore Foundation: February 22, 2022.  https://psnet.ahrq.gov/issue/request-proposals-clinical-quality-measures-improve-diagnosis A lack of consensus on measures for the effectiveness and ac…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44241/psn-pdf
    November 09, 2015 - The overlooked danger of delirium in hospitals. November 9, 2015 Boodman SG. The Atlantic. June 7, 2015. https://psnet.ahrq.gov/issue/overlooked-danger-delirium-hospitals Delirium is a common unintended consequence of hospitalization, most often following a surgical procedure. This magazine article discusses chara…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60663/psn-pdf
    January 01, 2021 - Apology laws and malpractice liability: what have we learned? July 8, 2020 Fields AC, Mello MM, Kachalia A. Apology laws and malpractice liability: what have we learned? BMJ Qual Saf. 2021;30(1):64-67. doi:10.1136/bmjqs-2020-010955. https://psnet.ahrq.gov/issue/apology-laws-and-malpractice-liability-what-have-we-l…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866638/psn-pdf
    September 04, 2024 - The problem with 'never events'. September 4, 2024 Zaslow J, Fortier J, Garber G. The problem with ‘never events’. BMJ Qual Saf. 2024;33(9):613-616. doi:10.1136/bmjqs-2023-016981. https://psnet.ahrq.gov/issue/problem-never-events Never events are serious, but preventable, adverse events that result in serious pati…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73502/psn-pdf
    July 14, 2021 - Toolkit to Improve Antibiotic Use in Long-Term Care. July 14, 2021 Rockville, MD: Agency for Healthcare Research and Quality; June 2021. https://psnet.ahrq.gov/issue/toolkit-improve-antibiotic-use-long-term-care The use of antibiotics should be monitored to reduce the potential for infection in care facilities. Thi…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46052/psn-pdf
    December 19, 2017 - Correlates of the third victim phenomenon. December 19, 2017 Russ MJ. Correlates of the Third Victim Phenomenon. Psychiatr Q. 2017;88(4):917-920. doi:10.1007/s11126-017-9511-1. https://psnet.ahrq.gov/issue/correlates-third-victim-phenomenon A sentinel event affects patients, their families, clinicians involved, an…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43948/psn-pdf
    May 20, 2015 - Human factors engineering: its place and potential in OR safety. May 20, 2015 Criscitelli T. Human factors engineering: its place and potential in OR safety. AORN J. 2015;101(5):571-3. doi:10.1016/j.aorn.2015.02.013. https://psnet.ahrq.gov/issue/human-factors-engineering-its-place-and-potential-or-safety Human fa…

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