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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43030/psn-pdf
    March 26, 2014 - Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors. March 26, 2014 ISMP Medication Safety Alert! Acute care edition. March 13, 2014;19:1-2,4-5.   https://psnet.ahrq.gov/issue/recommendations-practitioners-and-manufacturers-address-system-based- causes-vaccine-…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849133/psn-pdf
    May 17, 2023 - The association between patient safety culture and adverse events - a scoping review. May 17, 2023 Vikan M, Haugen AS, Bjørnnes AK, et al. The association between patient safety culture and adverse events – a scoping review. BMC Health Serv Res. 2023;23(1):300. doi:10.1186/s12913-023-09332-8. https://psnet.ahrq.go…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46931/psn-pdf
    January 15, 2019 - Strategies for optimizing OR drug safety. January 15, 2019 Meyer TA, McAllister RK. Pharmacy Practice News. March 19, 2018. https://psnet.ahrq.gov/issue/strategies-optimizing-or-drug-safety Perioperative adverse drug events are common and understudied. Reporting on the complexity of medication administration durin…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44378/psn-pdf
    August 05, 2015 - Advancing medication safety: establishing a National Action Plan for Adverse Drug Event Prevention. August 5, 2015 Harris Y, Hu DJ, Lee C, et al. Advancing Medication Safety: Establishing a National Action Plan for Adverse Drug Event Prevention. Jt Comm J Qual Patient Saf. 2015;41(8):351-60. https://psnet.ahrq.gov…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837040/psn-pdf
    May 04, 2022 - Use duodenoscopes with innovative designs to enhance safety: FDA Safety Communication. May 4, 2022 Silver Spring, MD: US Food and Drug Administration; April 5, 2022. https://psnet.ahrq.gov/issue/use-duodenoscopes-innovative-designs-enhance-safety-fda-safety- communication The challenge of medical device steriliza…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866250/psn-pdf
    July 10, 2024 - Attention among health care professionals : a scoping review. July 10, 2024 Kissler MJ, Porter S, Knees M, et al. Attention among health care professionals : a scoping review. Ann Intern Med. 2024;177(7):941-952. doi:10.7326/m23-3229. https://psnet.ahrq.gov/issue/attention-among-health-care-professionals-scoping-r…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45440/psn-pdf
    November 09, 2016 - Safety lessons from the NIH Clinical Center. November 9, 2016 Gandhi TK. Safety Lessons from the NIH Clinical Center. N Engl J Med. 2016;375(18):1705-1707. https://psnet.ahrq.gov/issue/safety-lessons-nih-clinical-center System failures can remain undetected over time in large organizations. This perspective describ…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45782/psn-pdf
    January 18, 2017 - Standardization of inpatient handoff communication. January 18, 2017 Jewell JA. Standardization of Inpatient Handoff Communication. Pediatrics. 2016;138(5):e20162681. doi:10.1542/peds.2016-2681. https://psnet.ahrq.gov/issue/standardization-inpatient-handoff-communication Handoffs at shift changes are vulnerable to…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41546/psn-pdf
    December 29, 2014 - Using a logic model to design and evaluate quality and patient safety improvement programs. December 29, 2014 Goeschel CA, Weiss WM, Pronovost P. Using a logic model to design and evaluate quality and patient safety improvement programs. Int J Qual Health Care. 2012;24(4):330-7. doi:10.1093/intqhc/mzs029. https://…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47646/psn-pdf
    February 06, 2019 - Systematic review of computerized prescriber order entry and clinical decision support. February 6, 2019 Vélez-Díaz-Pallarés M, Pérez-Menéndez-Conde C, Bermejo-Vicedo T. Systematic review of computerized prescriber order entry and clinical decision support. Am J Health Syst Pharm. 2018;75(23):1909-1921. doi:10.214…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849336/psn-pdf
    May 24, 2023 - AI may be on its way to your doctor’s office, but it’s not ready to see patients. May 24, 2023 Tahir D. KFF Health News. May 12, 2023. https://psnet.ahrq.gov/issue/ai-may-be-its-way-your-doctors-office-its-not-ready-see-patients Real-time use of artificial intelligence (AI) in health care settings continues to cau…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47881/psn-pdf
    July 10, 2019 - Cognitive Errors and Diagnostic Mistakes: A Case-Based Guide to Critical Thinking in Medicine. July 10, 2019 Howard J. Cham, Switzerland: Springer Nature Switzerland; 2019. ISBN: 9783319932231. https://psnet.ahrq.gov/issue/cognitive-errors-and-diagnostic-mistakes-case-based-guide-critical-thinking- medicine Cogni…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853058/psn-pdf
    August 30, 2023 - Diagnostic reliability in teledermatology: a systematic review and a meta-analysis. August 30, 2023 Bourkas AN, Barone N, Bourkas MEC, et al. Diagnostic reliability in teledermatology: a systematic review and a meta-analysis. BMJ Open. 2023;13(8):e068207. doi:10.1136/bmjopen-2022-068207. https://psnet.ahrq.gov/iss…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837630/psn-pdf
    July 06, 2022 - Mandating limits on workload, duty, and speed in radiology. July 6, 2022 Alexander R, Waite S, Bruno MA, et al. Mandating limits on workload, duty, and speed in radiology. Radiology. 2022:212631. doi:10.1148/radiol.212631. https://psnet.ahrq.gov/issue/mandating-limits-workload-duty-and-speed-radiology To reduce m…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40404/psn-pdf
    February 10, 2015 - The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths a year—and aim to do even better. February 10, 2015 Pryor D, Hendrich A, Henkel RJ, et al. The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths a year--and aim to do even better.…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45188/psn-pdf
    June 01, 2016 - Reporting and second-order problem solving can turn short-term fixes into long-term remedies. June 1, 2016 ISMP Medication Safety Alert! Acute Care Edition. May 19, 2016;21:1-4. https://psnet.ahrq.gov/issue/reporting-and-second-order-problem-solving-can-turn-short-term-fixes-long- term-remedies Workarounds are pr…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45530/psn-pdf
    October 19, 2016 - As a critical behavior to improve quality and patient safety in health care: speaking up! October 19, 2016 Nacioglu A. As a critical behavior to improve quality and patient safety in health care: speaking up!. Safety in Health. 2016;2(1). doi:10.1186/s40886-016-0021-x. https://psnet.ahrq.gov/issue/critical-behavio…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73476/psn-pdf
    July 07, 2021 - The role of apology laws in medical malpractice. July 7, 2021 Ross NE, Newman WJ. J Am Acad Psychiatry Law. 2021;49(3):406-414. https://psnet.ahrq.gov/issue/role-apology-laws-medical-malpractice Open disclosure of errors and adverse events is increasingly encouraged in healthcare, but clinicians frequently ci…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39731/psn-pdf
    August 04, 2010 - Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration. August 4, 2010 Yamamoto LG, Kanemori J. Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration. Am J Emerg Med. 2010;28(5):588-92. doi:10.1016/j.ajem.2009.02.009. https://ps…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40281/psn-pdf
    August 25, 2011 - Effects of a clinical pharmacist service on health-related quality of life and prescribing of drugs: a randomised controlled trial. August 25, 2011 Bladh L, Ottosson E, Karlsson J, et al. Effects of a clinical pharmacist service on health-related quality of life and prescribing of drugs: a randomised controlled tr…