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  1. 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…
  2. 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…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44298/psn-pdf
    July 08, 2015 - Preparing challenging medications for barcode scanning. July 8, 2015 Waxlax TJ. Preparing challenging medications for barcode scanning. Am J Health Syst Pharm. 2015;72(13):1089-90. doi:10.2146/ajhp140454. https://psnet.ahrq.gov/issue/preparing-challenging-medications-barcode-scanning Barcode scanning can reduce me…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42235/psn-pdf
    June 03, 2013 - Surgical safety checklist: implementation in an ambulatory surgical facility. June 3, 2013 Morgan PJ, Cunningham L, Mitra S, et al. Surgical safety checklist: implementation in an ambulatory surgical facility. Can J Anaesth. 2013;60(6):528-38. doi:10.1007/s12630-013-9916-8. https://psnet.ahrq.gov/issue/surgical-sa…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47994/psn-pdf
    July 16, 2019 - What's in a name? Newborn naming conventions and wrong-patient errors. July 16, 2019 ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019. https://psnet.ahrq.gov/issue/whats-name-newborn-naming-conventions-and-wrong-patient-errors Newborns assigned temporary names are at increased risk for patient misi…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37117/psn-pdf
    October 04, 2011 - Language barriers to prescriptions for patients with limited English proficiency: a survey of pharmacies. October 4, 2011 Bradshaw M, Tomany-Korman S, Flores G. Language barriers to prescriptions for patients with limited English proficiency: a survey of pharmacies. Pediatrics. 2007;120(2):e225-35. https://psnet.a…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74276/psn-pdf
    January 19, 2022 - Guideline for Prevention of Unintentionally Retained Surgical Items. January 19, 2022 Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6. doi:10.1002/aorn.13579. https://psnet.ahrq.gov/issue/guideline-prevention-unintentionally-retained-surgical-items Retained su…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60288/psn-pdf
    April 29, 2020 - Do some surgical implants do more harm than good? April 29, 2020 Groopman J. New Yorker Online. April 13, 2020.  https://psnet.ahrq.gov/issue/do-some-surgical-implants-do-more-harm-good Medical devices support quality of life but must be designed appropriately and managed carefully to ensure safety over time.…
  9. 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…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74756/psn-pdf
    February 09, 2022 - Medication errors in overweight and obese pediatric patients: a systematic review. February 9, 2022 Procaccini D, Kim JM, Lobner K, et al. Medication errors in overweight and obese pediatric patients: a systematic review. Jt Comm J Qual Patient Saf. 2022;48(3):154-164. doi:10.1016/j.jcjq.2021.12.005. https://psnet…
  11. 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…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40287/psn-pdf
    March 16, 2011 - The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names. March 16, 2011 Darker IT, Gerret D, Filik R, et al. The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names. Ergonomics. 2011;54(1):21-33. doi:10.1080/…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44990/psn-pdf
    July 11, 2017 - Automatic errors: a case series on the errors inherent in electronic prescribing. July 11, 2017 Lourenco LM, Bursua A, Groo VL. Automatic Errors: A Case Series on the Errors Inherent in Electronic Prescribing. J Gen Intern Med. 2016;31(7):808-811. doi:10.1007/s11606-016-3606-5. https://psnet.ahrq.gov/issue/automat…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44531/psn-pdf
    September 30, 2015 - Never Events for Hospital Care in Canada: Safer Care for Patients. September 30, 2015 Toronto, ON: Health Quality Ontario and the Canadian Patient Safety Institute; September 2015. ISBN: 9781460666180. https://psnet.ahrq.gov/issue/never-events-hospital-care-canada-safer-care-patients The never events list was dev…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43379/psn-pdf
    August 14, 2014 - Unit of measurement used and parent medication dosing errors. August 14, 2014 Yin S, Dreyer BP, Ugboaja DC, et al. Unit of measurement used and parent medication dosing errors. Pediatrics. 2014;134(2):e354-61. doi:10.1542/peds.2014-0395. https://psnet.ahrq.gov/issue/unit-measurement-used-and-parent-medication-dosi…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60192/psn-pdf
    April 01, 2020 - Effective Reporting Could Improve Safe Use of Electronic Health Records. April 1, 2020 Philadelphia, PA: Pew Charitable Trusts; March 2020. https://psnet.ahrq.gov/issue/effective-reporting-could-improve-safe-use-electronic-health-records Electronic health records both enhance and challenge the safety of care proce…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39119/psn-pdf
    November 25, 2009 - Effect of a weight-based prescribing method within an electronic health record on prescribing errors. November 25, 2009 Ginzburg R, Barr WB, Harris M, et al. Effect of a weight-based prescribing method within an electronic health record on prescribing errors. Am J Health Syst Pharm. 2009;66(22):2037-41. doi:10.214…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47925/psn-pdf
    August 21, 2019 - Second victims and mindfulness: a systematic review. August 21, 2019 S Miller C, Scott SD, Beck M. Second victims and mindfulness: a systematic review. J Patient Saf Risk Manag. 2019;24(3):108-117. doi:10.1177/2516043519838176. https://psnet.ahrq.gov/issue/second-victims-and-mindfulness-systematic-review The secon…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40992/psn-pdf
    December 15, 2011 - Should patients get direct access to their laboratory test results?: An answer with many questions. December 15, 2011 Giardina TD, Singh H. Should patients get direct access to their laboratory test results? An answer with many questions. JAMA. 2011;306(22):2502-2503. doi:10.1001/jama.2011.1797. https://psnet.ahrq…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46701/psn-pdf
    December 20, 2017 - The other big drug problem: older people taking too many pills. December 20, 2017 Boodman SG. Washington Post. December 9, 2017. https://psnet.ahrq.gov/issue/other-big-drug-problem-older-people-taking-too-many-pills The prevalence of polypharmacy among older patients represents an important concern for health care…