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8561. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37359/psn-pdf
      January 02, 2017 - Case study: preventing surgical complications at Baystate Medical Center. January 2, 2017 Fitzgerald J, Kanter G, Benjamin EM. Case Study: Preventing Surgical Complications at Baystate Medical Center. The Joint Commission Journal on Quality and Patient Safety. 2016;33(11). doi:10.1016/s1553- 7250(07)33076-6. http…

8562. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74259/psn-pdf
      January 19, 2022 - Diagnostic reasoning in cardiovascular medicine. January 19, 2022 Brush JE, Sherbino J, Norman GR. Diagnostic reasoning in cardiovascular medicine. BMJ. 2022;376:e064389. doi:10.1136/bmj-2021-064389. https://psnet.ahrq.gov/issue/diagnostic-reasoning-cardiovascular-medicine Misdiagnosis of heart failure can lead to…

8563. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73872/psn-pdf
      September 22, 2021 - Parenteral nutrition safety. September 22, 2021 Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20. https://psnet.ahrq.gov/issue/parenteral-nutrition-safety Parenteral nutrition (PN) processes contain various steps that are prone to errors resulting in patient harm. This article discusses …

8564. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41683/psn-pdf
      September 19, 2012 - Techniques to improve patient safety in hospitals: what nurse administrators need to know. September 19, 2012 Fagan MJ. Techniques to improve patient safety in hospitals: what nurse administrators need to know. J Nurs Adm. 2012;42(9):426-430. doi:10.1097/NNA.0b013e3182664df5. https://psnet.ahrq.gov/issue/technique…

8565. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43411/psn-pdf
      October 01, 2014 - Analysis of medication errors in simulated pediatric resuscitation by residents. October 1, 2014 Porter E, Barcega B, Kim TY. Analysis of medication errors in simulated pediatric resuscitation by residents. West J Emerg Med. 2014;15(4):486-90. doi:10.5811/westjem.2014.2.17922. https://psnet.ahrq.gov/issue/analysis…

8566. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44678/psn-pdf
      July 05, 2017 - Patient Safety Risk Management Playbook. July 5, 2017 Chicago, IL: American Society for Healthcare Risk Management; 2015. https://psnet.ahrq.gov/issue/patient-safety-risk-management-playbook Proactive risk management is an important component to improving the safety of care. Exploring principles of high reliabilit…

8567. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/860400/psn-pdf
      January 10, 2024 - AHA Patient Safety Initiative. January 10, 2024 American Hospital Association. https://psnet.ahrq.gov/issue/aha-patient-safety-initiative Leadership at the organization and system level is crucial to gaining improvement traction and sustainability. This initiative centers on safety culture, care inequities, and wo…

8568. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60563/psn-pdf
      June 03, 2020 - ‘Last responders’ seek to expand postmortem COVID testing In unexplained deaths. June 3, 2020 Andrews M. Kaiser News Network. May 19, 2020. https://psnet.ahrq.gov/issue/last-responders-seek-expand-postmortem-covid-testing-unexplained-deaths Post-mortem examination is an important tool for determining if misdiagnos…

8569. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44880/psn-pdf
      September 06, 2016 - Drug shortages forcing hard decisions on rationing treatments. September 6, 2016 Fink S. New York Times. January 29, 2016. https://psnet.ahrq.gov/issue/drug-shortages-forcing-hard-decisions-rationing-treatments Drug shortages have become a routine challenge in medicine. Reporting on the impact of medication short…

8570. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45646/psn-pdf
      November 23, 2016 - Patient safety in the emergency department. November 23, 2016 Farmer B. Patient Safety in the Emergency Department. Emerg Med (N Y). 2016;48(9). doi:10.12788/emed.2016.0052. https://psnet.ahrq.gov/issue/patient-safety-emergency-department Emergency departments are high-risk environments due to the urgency of care …

8571. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46494/psn-pdf
      January 24, 2018 - Complications. January 24, 2018 Anaesthesia. 2018;73(suppl 1):3-101. https://psnet.ahrq.gov/issue/complications Study of complications can provide insights into presurgical patient counseling, risk assessment, and medical harm prevention. Articles in this special issue explore complications in anesthesia, includin…

8572. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43151/psn-pdf
      April 30, 2014 - Open for Better Care. April 30, 2014 Health Quality & Safety Commission New Zealand. https://psnet.ahrq.gov/issue/open-better-care This Web site hosts tools and resources associated with a national campaign to augment patient care. The initiative aims to build collaborative programs across New Zealand to reduce fa…

8573. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867648/psn-pdf
      January 01, 2023 - Opioid Taskforce Playbook. January 1, 2023 College of Healthcare Information Management Executives; 2023. Opioid Taskforce Playbook. https://psnet.ahrq.gov/issue/opioid-taskforce-playbook Hospitals play an important role in identifying and preventing the misuse and abuse of prescription opioids. This Opioid Playbo…

8574. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39715/psn-pdf
      May 25, 2011 - Barriers to incident notification in a regional prehospital setting. May 25, 2011 Jennings PA, Stella J. Barriers to incident notification in a regional prehospital setting. Emerg Med J. 2011;28(6):526-9. doi:10.1136/emj.2010.090738. https://psnet.ahrq.gov/issue/barriers-incident-notification-regional-prehospital-…

8575. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47621/psn-pdf
      May 11, 2019 - 2018 update on pediatric medical overuse: a review. May 11, 2019 Coon ER, Quinonez RA, Morgan DJ, et al. 2018 Update on Pediatric Medical Overuse: A Review. JAMA Pediatr. 2019;173(4):379-384. doi:10.1001/jamapediatrics.2018.5550. https://psnet.ahrq.gov/issue/2018-update-pediatric-medical-overuse-review Overuse of …

8576. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34991/psn-pdf
      June 22, 2009 - Use of failure mode and effects analysis in improving the safety of i.v. drug administration. June 22, 2009 Adachi W, Lodolce AE. Use of failure mode and effects analysis in improving the safety of i.v. drug administration. Am J Health Syst Pharm. 2005;62(9):917-20. https://psnet.ahrq.gov/issue/use-failure-mode-an…

8577. Improving Care Transitions of Older Adults | PSNet
      psnet.ahrq.gov/training-catalog/improving-care-transitions-older-adults
      Improving Care Transitions of Older Adults Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization RCTCLEARN.NET Event Description: This program focu…

8578. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60264/psn-pdf
      January 14, 2021 - COVID-19 Content. ISMP Medication Safety Alert! January 14, 2021 March 2020--January 2021. https://psnet.ahrq.gov/issue/special-editions-covid-19-ismp-medication-safety-alert Medication safety is improved through the sharing of frontline improvement experiences and concerns. These articles share recommendations to…

8579. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/847734/psn-pdf
      April 19, 2023 - Patient safety tools for primary care. April 19, 2023 Domdera J. Fam Pract Manag. 2023;30(2):24-28. https://psnet.ahrq.gov/issue/patient-safety-tools-primary-care A large segment of patients receives outpatient care. This commentary suggests that high-reliability concepts be applied in the primary care environment…

8580. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42460/psn-pdf
      July 31, 2013 - Effectiveness of the surgical safety checklist in a high standard care environment. July 31, 2013 Lübbeke A, Hovaguimian F, Wickboldt N, et al. Effectiveness of the surgical safety checklist in a high standard care environment. Med Care. 2013;51(5):425-9. doi:10.1097/MLR.0b013e31828d1489. https://psnet.ahrq.gov/is…