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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43945/psn-pdf
    September 09, 2015 - Hospital and procedure incidence of pediatric retained surgical items. September 9, 2015 Wang B, Tashiro J, Perez EA, et al. Hospital and procedure incidence of pediatric retained surgical items. J Surg Res. 2015;198(2):400-5. doi:10.1016/j.jss.2015.03.054. https://psnet.ahrq.gov/issue/hospital-and-procedure-incid…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34594/psn-pdf
    January 04, 2017 - John M. Eisenberg Patient Safety Awards. The Leapfrog Group for Patient Safety: rewarding higher standards. January 4, 2017 Eikel C, Delbanco S. John M. Eisenberg Patient Safety Awards. The Leapfrog Group for Patient Safety: rewarding higher standards. Jt Comm J Qual Saf. 2003;29(12):634-9. https://psnet.ahrq.gov/…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45826/psn-pdf
    January 18, 2017 - Ensuring staff safety when treating potentially violent patients. January 18, 2017 Roca RP, Charen B, Boronow J. Ensuring Staff Safety When Treating Potentially Violent Patients. JAMA. 2016;316(24):2669-2670. doi:10.1001/jama.2016.18260. https://psnet.ahrq.gov/issue/ensuring-staff-safety-when-treating-potentially-…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37709/psn-pdf
    April 23, 2008 - Inappropriate medication use in the elderly: results from a quality improvement project in 99 primary care practices. April 23, 2008 Wessell AM, Nietert PJ, Jenkins RG, et al. Inappropriate medication use in the elderly: Results from a quality improvement project in 99 primary care practices. Am J Geriatr Pharmacot…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46554/psn-pdf
    October 25, 2017 - Severe hyperglycemia in patients incorrectly using insulin pens at home. October 25, 2017 National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. October 12, 2017. https://psnet.ahrq.gov/issue/severe-hyperglycemia-patients-incorrect…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44009/psn-pdf
    July 18, 2016 - Automated communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors. July 18, 2016 Smith KJ, Handler S, Kapoor WN, et al. Automated Communication Tools and Computer-Based Medication Reconciliation to Decrease Hospital Discharge Medication Errors. Am J Med Qua…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45094/psn-pdf
    May 04, 2016 - Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care. May 4, 2016 Washington, DC: United States Government Accountability Office; March 18, 2016. Publication GAO-16- 328. https://psnet.ahrq.gov/issue/actions-needed-improve-newly-enrolled-veterans-access-primary-care This analysis found that s…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851204/psn-pdf
    July 05, 2023 - Drugmakers are abandoning cheap generics, and now US cancer patients can’t get meds. July 5, 2023 Allen A. KFF Health News. June 21, 2023. https://psnet.ahrq.gov/issue/drugmakers-are-abandoning-cheap-generics-and-now-us-cancer-patients- cant-get-meds A variety of supply-chain, quality control, and economic factor…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45082/psn-pdf
    April 27, 2016 - Surgeons must tell patients of double-booked surgeries, new guidelines say. April 27, 2016 Abelson J, Staltzman J. Boston Globe. April 13, 2016. https://psnet.ahrq.gov/issue/surgeons-must-tell-patients-double-booked-surgeries-new-guidelines-say Although scheduling overlapping surgeries may improve operating room e…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840163/psn-pdf
    November 16, 2022 - Deep Dive: Racial and Ethnic Disparities in Health and Healthcare. November 16, 2022 Plymouth Meeting, PA: ECRI and the Institute for Safe Medication Practices; 2022. https://psnet.ahrq.gov/issue/deep-dive-racial-and-ethnic-disparities-health-and-healthcare Racist behavior directed at either patients or clinicians…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34643/psn-pdf
    December 23, 2008 - The health care cost of drug-related morbidity and mortality in nursing facilities. December 23, 2008 Bootman JL, Harrison DL, Cox E. The health care cost of drug-related morbidity and mortality in nursing facilities. Arch Intern Med. 1997;157(18):2089-96. https://psnet.ahrq.gov/issue/health-care-cost-drug-related…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44123/psn-pdf
    July 11, 2018 - The 2014 John M. Eisenberg Patient Safety and Quality Awards. July 11, 2018 Jt Comm J Qual Patient Saf. 2015;41(5):195-211. https://psnet.ahrq.gov/issue/2014-john-m-eisenberg-patient-safety-and-quality-awards Articles in this special issue highlight the achievements of the 2014 John M. Eisenberg Patient Safety and…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44425/psn-pdf
    February 24, 2016 - Dangerous doses. February 24, 2016 Roe S, King K. Chicago Tribune. February 10–13, 2016. https://psnet.ahrq.gov/issue/dangerous-doses Drug interactions can be hazardous to patients, particularly when combined with risk factors such as age and use of medications for chronic conditions. This series of news reports d…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72499/psn-pdf
    November 25, 2020 - Transformational improvement in quality care and health systems: the next decade. November 25, 2020 Braithwaite J, Vincent CA, Garcia-Elorrio E, et al. Transformational improvement in quality care and health systems: the next decade. BMC Med. 2020;18(1):340. doi:10.1186/s12916-020-01739-y. https://psnet.ahrq.gov/i…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43307/psn-pdf
    September 26, 2016 - Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting. September 26, 2016 Prakash V, Koczmara C, Savage P, et al. Mitigating errors caused by interruptions during medication verification and administration: interven…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74011/psn-pdf
    October 27, 2021 - Dashboards for visual display of patient safety data: a systematic review. October 27, 2021 Murphy DR, Savoy A, Satterly T, et al. Dashboards for visual display of patient safety data: a systematic review. BMJ Health Care Inform. 2021;28(1):e100437. doi:10.1136/bmjhci-2021-100437. https://psnet.ahrq.gov/issue/dash…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44386/psn-pdf
    August 12, 2015 - Using simulation to improve systems. August 12, 2015 Lundberg PW, Korndorffer JR. Using Simulation to Improve Systems. Surg Clin North Am. 2015;95(4):885- 92. doi:10.1016/j.suc.2015.04.007. https://psnet.ahrq.gov/issue/using-simulation-improve-systems Safety approaches from aviation that can be applied to health c…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854382/psn-pdf
    October 11, 2023 - Battling alarm fatigue in the pediatric intensive care unit. October 11, 2023 Herrera H, Wood D. Battling alarm fatigue in the pediatric intensive care unit. Crit Care Nurs Clin North Am. 2023;35(3):347-355. doi:10.1016/j.cnc.2023.05.003. https://psnet.ahrq.gov/issue/battling-alarm-fatigue-pediatric-intensive-care-…
  19. 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…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43078/psn-pdf
    June 03, 2014 - The value of autopsies in the era of high-tech medicine: discrepant findings persist. June 3, 2014 Kuijpers CCHJ, Fronczek J, van de Goot FRW, et al. The value of autopsies in the era of high-tech medicine: discrepant findings persist. J Clin Pathol. 2014;67(6):512-9. doi:10.1136/jclinpath-2013-202122. https://psn…