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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44944/psn-pdf
    July 01, 2016 - Managing and mitigating conflict in healthcare teams: an integrative review. July 1, 2016 Almost J, Wolff AC, Stewart-Pyne A, et al. Managing and mitigating conflict in healthcare teams: an integrative review. J Adv Nurs. 2016;72(7):1490-505. doi:10.1111/jan.12903. https://psnet.ahrq.gov/issue/managing-and-mitigat…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43118/psn-pdf
    April 16, 2014 - NCPDP Recommendations and Guidance for Standardizing the Dosing Designations on Prescription Container Labels of Oral Liquid Medications Version 1.0. April 16, 2014 Scottsdale, AZ: National Council for Prescription Drug Programs; March 2014. https://psnet.ahrq.gov/issue/ncpdp-recommendations-and-guidance-standardi…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42355/psn-pdf
    February 11, 2015 - Advancing Successful Care Transitions to Improve Outcomes. February 11, 2015 Society of Hospital Medicine https://psnet.ahrq.gov/issue/project-boost-mentored-implementation-program This Web site provides resources associated with the Better Outcomes for Older adults through Safe Transitions project, called Projec…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45756/psn-pdf
    December 21, 2016 - Accidental IV infusion of heparinized irrigation in the OR. December 21, 2016 ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3. https://psnet.ahrq.gov/issue/accidental-iv-infusion-heparinized-irrigation-or Accidental administration of irrigation solutions are a wrong-route error that can re…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837430/psn-pdf
    June 15, 2022 - Stop using these adult bed rails, warns the Consumer Product Safety Commission. June 15, 2022 Treisman R. National Public Radio. June 6, 2022 https://psnet.ahrq.gov/issue/stop-using-these-adult-bed-rails-warns-consumer-product-safety-commission Bedrails are used in hospitals and at home to minimize falls despite t…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47412/psn-pdf
    October 31, 2018 - The systems approach at the sharp end. October 31, 2018 Cross SRH. The systems approach at the sharp end. Future Healthc J. 2019;5(3):176-180. doi:10.7861/futurehosp.5-3-176. https://psnet.ahrq.gov/issue/systems-approach-sharp-end Systems solutions are often focused on creating improvements at the organizational o…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43394/psn-pdf
    July 30, 2014 - With oral chemotherapy, we simply must do better! July 30, 2014 ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4. https://psnet.ahrq.gov/issue/oral-chemotherapy-we-simply-must-do-better To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848825/psn-pdf
    May 10, 2023 - Laura Levis' death outside ER has changed hospital signage, lighting in Mass. May 10, 2023 Mullins L, Menard F. WBUR. April 27, 2023. https://psnet.ahrq.gov/issue/laura-levis-death-outside-er-has-changed-hospital-signage-lighting-mass Incomplete information and building design problems can reduce access to care an…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74859/psn-pdf
    February 23, 2022 - Characteristics of registered clinical trials assessing strategies of medication errors prevention- an unusual cross sectional analysis. February 23, 2022 doi:http://doi.org/10.23750/abm.v92iS2.11507. https://psnet.ahrq.gov/issue/characteristics-registered-clinical-trials-assessing-strategies-medication-errors- p…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46746/psn-pdf
    March 07, 2018 - Safety with nebulized medications requires an interdisciplinary team approach. March 7, 2018 ISMP Medication Safety Alert! Acute care edition. February 22, 2018;23(4):1-5. https://psnet.ahrq.gov/issue/safety-nebulized-medications-requires-interdisciplinary-team-approach Myriad system and clinician failures can con…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44274/psn-pdf
    February 18, 2019 - Concepts for the development of a customizable checklist for use by patients. February 18, 2019 Fernando RJ, Shapiro FE, Rosenberg NM, et al. Concepts for the Development of a Customizable Checklist for Use by Patients. J Patient Saf. 2019;15(1):18-23. doi:10.1097/PTS.0000000000000203. https://psnet.ahrq.gov/issue…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48142/psn-pdf
    August 21, 2019 - Six ways to lower errors—and unnecessary surgeries—in radiology exams. August 21, 2019 Panner M. Forbes. August 12, 2019. https://psnet.ahrq.gov/issue/six-ways-lower-errors-and-unnecessary-surgeries-radiology-exams Diagnostic errors can result in harm across the spectrum of practice. Discussing cognitive and syste…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865493/psn-pdf
    April 03, 2024 - Implement strategies to prevent persistent medication errors and hazards: 2024. April 3, 2024 ISMP Medication Safety Alert! Acute Care. 2024;29(6):1-4. https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards-2024 Systemic failures can perpetuate unsafe care if a lack of p…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47904/psn-pdf
    April 24, 2019 - Air pressure: human factors are the key to a safer flight environment. April 24, 2019 Erich J. EMS World. April 2019;48:26-31. https://psnet.ahrq.gov/issue/air-pressure-human-factors-are-key-safer-flight-environment Air transport service combines risks associated with both aviation and prehospital trauma care. Thi…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45549/psn-pdf
    October 12, 2016 - Preventing diagnostic errors in primary care. October 12, 2016 Ely JW, Graber ML. Preventing Diagnostic Errors in Primary Care. Am Fam Physician. 2016;94(6):426-32. https://psnet.ahrq.gov/issue/preventing-diagnostic-errors-primary-care The Improving Diagnosis in Health Care report advocated for enhancing patient en…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73256/psn-pdf
    May 12, 2021 - Addiction treatment providers in Pa. face little state scrutiny despite harm to clients. May 12, 2021 Pattani A, Mahon E. Kaiser Health News.  April 30, 2021. https://psnet.ahrq.gov/issue/addiction-treatment-providers-pa-face-little-state-scrutiny-despite-harm-clients Systemic oversight weaknesses and lack of…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39265/psn-pdf
    February 03, 2010 - Intensive care unit alarms—how many do we need? February 3, 2010 Siebig S, Kuhls S, Imhoff M, et al. Intensive care unit alarms--how many do we need? Crit Care Med. 2010;38(2):451-6. doi:10.1097/CCM.0b013e3181cb0888. https://psnet.ahrq.gov/issue/intensive-care-unit-alarms-how-many-do-we-need This study found that …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45048/psn-pdf
    April 13, 2016 - Do not let "Depo-" medications be a depot for mistakes. April 13, 2016 ISMP Medication Safety Alert! Acute Care Edition. March 24, 2016;21:1-4. https://psnet.ahrq.gov/issue/do-not-let-depo-medications-be-depot-mistakes Confusion due to look-alike and sound-alike medications are known to contribute to medication err…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43331/psn-pdf
    July 09, 2014 - Open wide: looking into the safety culture of dental school clinics. July 9, 2014 Ramoni R, Walji MF, Tavares A, et al. Open wide: looking into the safety culture of dental school clinics. J Dent Edu. 2014;78(5):745-756. https://psnet.ahrq.gov/issue/open-wide-looking-safety-culture-dental-school-clinics Researche…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73379/psn-pdf
    June 09, 2021 - How medical jargon can make COVID health disparities even worse. June 9, 2021 Kritz F. Health Shots. National Public Radio; May 24, 2021. https://psnet.ahrq.gov/issue/how-medical-jargon-can-make-covid-health-disparities-even-worse Health literacy efforts address challenges related to both language and effecti…

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