-
psnet.ahrq.gov/node/73431/psn-pdf
June 23, 2021 - Drive to Deprescribe.
June 23, 2021
The Society for Post-Acute and Long-Term Care Medicine.
https://psnet.ahrq.gov/issue/drive-deprescribe
Polypharmacy is a known challenge to patient safety. This collective program encourages long-term care
organizations, physicians, and pharmacists to take part in a learning net…
-
psnet.ahrq.gov/node/37749/psn-pdf
July 16, 2018 - Practice advisory for the prevention and management of
operating room fires.
July 16, 2018
Fires AS of ATF on OR, Caplan RA, Barker SJ, et al. Practice advisory for the prevention and management
of operating room fires. Anesthesiology. 2008;108(5):786-801; quiz 971-2.
doi:10.1097/01.anes.0000299343.87119.a9.
htt…
-
psnet.ahrq.gov/node/39766/psn-pdf
August 18, 2010 - Paediatric dosing errors before and after electronic
prescribing.
August 18, 2010
Jani Y, Barber N, Wong ICK. Paediatric dosing errors before and after electronic prescribing. Qual Saf
Health Care. 2010;19(4):337-40. doi:10.1136/qshc.2009.033068.
https://psnet.ahrq.gov/issue/paediatric-dosing-errors-and-after-elec…
-
psnet.ahrq.gov/node/41972/psn-pdf
January 23, 2013 - Impact of a pharmacotherapy alerting system on
medication errors.
January 23, 2013
Natali BJ, Varkey AC, Garey KW, et al. Impact of a pharmacotherapy alerting system on medication errors.
American Journal of Health-System Pharmacy. 2012;70(1). doi:10.2146/ajhp120126.
https://psnet.ahrq.gov/issue/impact-pharmacothe…
-
psnet.ahrq.gov/node/42753/psn-pdf
November 20, 2013 - Dealing with a medical mistake: should physicians
apologize to patients?
November 20, 2013
Tabler NG Jr.
https://psnet.ahrq.gov/issue/dealing-medical-mistake-should-physicians-apologize-patients
This article discusses how apologies address patients' needs when a medical mistake has occurred and
how such disclosur…
-
psnet.ahrq.gov/node/36431/psn-pdf
March 28, 2011 - Using the internet to deliver education on drug safety.
March 28, 2011
Franklin B, O'Grady K, Parr J, et al. Using the internet to deliver education on drug safety. Qual Saf Health
Care. 2006;15(5):329-33.
https://psnet.ahrq.gov/issue/using-internet-deliver-education-drug-safety
The project team implemented a web-…
-
psnet.ahrq.gov/node/50727/psn-pdf
December 11, 2019 - Your diagnosis was wrong. Could doctor bias have been
a factor?
December 11, 2019
Glicksman E. Washington Post. November 17, 2019.
https://psnet.ahrq.gov/issue/your-diagnosis-was-wrong-could-doctor-bias-have-been-factor
Unconscious assumptions and biases are known contributors to poor decision-making. This news st…
-
psnet.ahrq.gov/node/37653/psn-pdf
May 14, 2008 - Getting boards on board: engaging governing boards in
quality and safety.
May 14, 2008
Conway JB. Getting boards on board: engaging governing boards in quality and safety. Jt Comm J Qual
Saf. 2008;34(4):214-220.
https://psnet.ahrq.gov/issue/getting-boards-board-engaging-governing-boards-quality-and-safety
This a…
-
psnet.ahrq.gov/node/42344/psn-pdf
September 24, 2016 - Strategies for preventing distractions and interruptions in
the OR.
September 24, 2016
Clark GJ. Strategies for preventing distractions and interruptions in the OR. AORN J. 2013;97(6):702-707.
doi:10.1016/j.aorn.2013.01.018.
https://psnet.ahrq.gov/issue/strategies-preventing-distractions-and-interruptions-or
Dist…
-
psnet.ahrq.gov/node/40696/psn-pdf
December 01, 2011 - Rapid response systems: a prospective study of
response times.
December 1, 2011
Adelstein B-A, Piza MA, Nayyar V, et al. Rapid response systems: a prospective study of response times. J
Crit Care. 2011;26(6):635.e11-8. doi:10.1016/j.jcrc.2011.03.013.
https://psnet.ahrq.gov/issue/rapid-response-systems-prospective-…
-
psnet.ahrq.gov/node/43318/psn-pdf
July 02, 2014 - Sign up to Safety.
July 2, 2014
National Health Service.
https://psnet.ahrq.gov/issue/sign-safety
Through a coordinated effort to set goals and devise plans to improve safety in hospitals, the Sign up to
Safety campaign aims to prevent 6000 patient deaths in the next 3 years in National Health Service
facilities.…
-
psnet.ahrq.gov/node/37704/psn-pdf
April 23, 2008 - Decreasing paediatric prescribing errors in a district
general hospital.
April 23, 2008
Davey AL, Britland A, Naylor RJ. Decreasing paediatric prescribing errors in a district general hospital.
Qual Saf Health Care. 2008;17(2):146-9. doi:10.1136/qshc.2006.021212.
https://psnet.ahrq.gov/issue/decreasing-paediatric-…
-
psnet.ahrq.gov/node/36039/psn-pdf
March 02, 2011 - The effects of on-duty napping on intern sleep time and
fatigue.
March 2, 2011
Arora V, Dunphy C, Chang VY, et al. The effects of on-duty napping on intern sleep time and fatigue. Ann
Intern Med. 2006;144(11):792-8.
https://psnet.ahrq.gov/issue/effects-duty-napping-intern-sleep-time-and-fatigue
The investigators …
-
psnet.ahrq.gov/node/46466/psn-pdf
July 11, 2018 - Distinct newborn identification requirement.
July 11, 2018
R3 Report. June 25, 2018;7:1-2.
https://psnet.ahrq.gov/issue/distinct-newborn-identification-requirement
Neonatal patients are at risk for misidentification due to communication challenges and lack of
distinguishable features. This report highlights new Jo…
-
psnet.ahrq.gov/node/40903/psn-pdf
March 08, 2015 - Does your patient really understand?
March 8, 2015
Huff C. Does your patient really understand? Hospitals & health networks. 2011;85(10):34-5, 37-8, 2.
https://psnet.ahrq.gov/issue/does-your-patient-really-understand
This article discusses health literacy and describes an initiative to reduce gaps in understanding …
-
psnet.ahrq.gov/node/41955/psn-pdf
January 09, 2013 - Making Medical Devices Safer at Home.
January 9, 2013
Consumer Updates. Silver Spring, MD: US Food and Drug Administration; December 12, 2012.
https://psnet.ahrq.gov/issue/making-medical-devices-safer-home
Highlighting concerns associated with patients' use of medical devices at home, such as difficulty
understand…
-
psnet.ahrq.gov/node/42830/psn-pdf
December 18, 2013 - How to Identify and Address Unsafe Conditions
Associated With Health IT.
December 18, 2013
Wallace C, Zimmer KP, Possanza L, Giannini R, Solomon R. Washington, DC: Office of the National
Coordinator for Health Information Technology; November 15, 2013.
https://psnet.ahrq.gov/issue/how-identify-and-address-unsafe-c…
-
psnet.ahrq.gov/node/40668/psn-pdf
March 04, 2015 - Body CT: technical advances for improving safety.
March 4, 2015
Marin D, Nelson RC, Rubin GD, et al. Body CT: technical advances for improving safety. AJR Am J
Roentgenol. 2011;197(1):33-41. doi:10.2214/AJR.11.6755.
https://psnet.ahrq.gov/issue/body-ct-technical-advances-improving-safety
This article explores risk…
-
psnet.ahrq.gov/node/42332/psn-pdf
June 12, 2013 - Quality improvement through implementation of
discharge order reconciliation.
June 12, 2013
Lu Y, Clifford P, Bjorneby A, et al. Quality improvement through implementation of discharge order
reconciliation. Am J Health Syst Pharm. 2013;70(9):815-20. doi:10.2146/ajhp120050.
https://psnet.ahrq.gov/issue/quality-impr…
-
psnet.ahrq.gov/node/40568/psn-pdf
June 29, 2011 - Tubing misconnections: normalization of deviance.
June 29, 2011
Simmons D, Symes L, Guenter P, et al. Tubing misconnections: normalization of deviance. Nutr Clin Pract.
2011;26(3):286-293. doi:10.1177/0884533611406134.
https://psnet.ahrq.gov/issue/tubing-misconnections-normalization-deviance
Analyzing published ca…