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  1. 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…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38559/psn-pdf
    June 16, 2009 - Regional surveillance of emergency-department visits for outpatient adverse drug events. June 16, 2009 Capuano A, Irpino A, Gallo M, et al. Regional surveillance of emergency-department visits for outpatient adverse drug events. Eur J Clin Pharmacol. 2009;65(7):721-8. doi:10.1007/s00228-009-0641-8. https://psnet.a…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842431/psn-pdf
    January 11, 2023 - Confronting racism in pediatric care. January 11, 2023 Danielson B. Confronting racism in pediatric care. Health Affairs. 2022;41(11):1681-1685. doi:10.1377/hlthaff.2022.01157. https://psnet.ahrq.gov/issue/confronting-racism-pediatric-care Racism is a patient safety issue that is gaining the increased attention ne…
  4. 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…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47792/psn-pdf
    May 01, 2019 - New evidence on stemming low-value prescribing. May 1, 2019 Sacarny A, Barnett ML, Agrawal S. NEJM Catalyst. April 10, 2019. https://psnet.ahrq.gov/issue/new-evidence-stemming-low-value-prescribing Overprescribing contributes to polypharmacy, antibiotic resistance, and opioid misuse. This commentary discusses stra…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42102/psn-pdf
    April 03, 2013 - Enhancing electronic health record usability in pediatric patient care: a scenario-based approach. April 3, 2013 Patterson ES, Zhang J, Abbott P, et al. Enhancing electronic health record usability in pediatric patient care: a scenario-based approach. Jt Comm J Qual Patient Saf. 2013;39(3):129-135. https://psnet.a…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42985/psn-pdf
    February 26, 2014 - Confusion—specimen mix-up in dermatopathology and measures to prevent and detect it. February 26, 2014 Weyers W. Confusion-specimen mix-up in dermatopathology and measures to prevent and detect it. Dermatol Pract Concept. 2014;4(1):27-42. doi:10.5826/dpc.0401a04. https://psnet.ahrq.gov/issue/confusion-specimen-mix…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45801/psn-pdf
    August 03, 2017 - Overcoming diagnostic errors in medical practice. August 3, 2017 Bordini BJ, Stephany A, Kliegman RM. Overcoming Diagnostic Errors in Medical Practice. J Pediatr. 2017;185. doi:10.1016/j.jpeds.2017.02.065. https://psnet.ahrq.gov/issue/overcoming-diagnostic-errors-medical-practice This commentary describes a progra…
  9. 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…
  10. 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…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41296/psn-pdf
    April 11, 2012 - I-PASS, a mnemonic to standardize verbal handoffs. April 11, 2012 Starmer AJ, Spector ND, Srivastava R, et al. I-pass, a mnemonic to standardize verbal handoffs. Pediatrics. 2012;129(2):201-4. doi:10.1542/peds.2011-2966. https://psnet.ahrq.gov/issue/i-pass-mnemonic-standardize-verbal-handoffs Poor communication at…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838638/psn-pdf
    September 01, 2012 - Directed peer review in surgical pathology. September 1, 2012 Smith ML, Raab SS. Directed peer review in surgical pathology. Adv Anat Pathol. 2012;19(5):331-337. doi:10.1097/pap.0b013e31826661b7. https://psnet.ahrq.gov/issue/directed-peer-review-surgical-pathology Diagnostic error in pathology can result in delaye…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38276/psn-pdf
    December 10, 2008 - Addressing delays in medication administration for patients transferred from the hospital to the nursing home: a pilot quality improvement project. December 10, 2008 Ward KT, Bates-Jensen B, Eslami MS, et al. Addressing delays in medication administration for patients transferred from the hospital to the nursing h…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36664/psn-pdf
    May 27, 2011 - A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions. May 27, 2011 Karnon J, McIntosh A, Dean JE, et al. A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions. Saf Sci. 2006;45(4).…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35470/psn-pdf
    July 10, 2008 - Prevention of fall-related injuries in long-term care: a randomized controlled trial of staff education. July 10, 2008 Ray WA, Taylor JA, Brown AK, et al. Prevention of fall-related injuries in long-term care: a randomized controlled trial of staff education. Arch Intern Med. 2005;165(19):2293-8. https://psnet.ahr…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38925/psn-pdf
    September 16, 2009 - A literature review of the individual and systems factors that contribute to medication errors in nursing practice. September 16, 2009 Brady A-M, Malone A-M, Fleming S. A literature review of the individual and systems factors that contribute to medication errors in nursing practice. J Nurs Manag. 2009;17(6):679-97…
  17. 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…
  18. 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 …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41378/psn-pdf
    March 04, 2015 - Clinically missed cancer: how effectively can radiologists use computer-aided detection? March 4, 2015 Nishikawa RM, Schmidt RA, Linver MN, et al. Clinically Missed Cancer: How Effectively Can Radiologists Use Computer-Aided Detection? American Journal of Roentgenology. 2012;198(3). doi:10.2214/ajr.11.6423. https…
  20. 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…