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6821. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39801/psn-pdf
      December 21, 2014 - Gossypiboma: tales of lost sponges and lessons learned. December 21, 2014 McIntyre LK. Gossypiboma. Archives of Surgery. 2010;145(8). doi:10.1001/archsurg.2010.152. https://psnet.ahrq.gov/issue/gossypiboma-tales-lost-sponges-and-lessons-learned This study describes successful efforts to reduce retained surgical spo…

6822. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39081/psn-pdf
      September 27, 2016 - Medication room madness: calming the chaos. September 27, 2016 Conrad C, Fields W, McNamara T, et al. Medication room madness: calming the chaos. J Nurs Care Qual. 2010;25(2):137-144. doi:10.1097/NCQ.0b013e3181c3695d. https://psnet.ahrq.gov/issue/medication-room-madness-calming-chaos Through space and process desi…

6823. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50605/psn-pdf
      October 30, 2019 - Report focuses on risk to patients from ED errors. October 30, 2019 Palmer J. Patient Saf Qual Healthcare. Sept/Oct 2019. https://psnet.ahrq.gov/issue/report-focuses-risk-patients-ed-errors The pace of emergency care delivery can reduce reliability. This news story discusses an analysis of medical liability claims…

6824. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38370/psn-pdf
      August 22, 2009 - Monitoring for medication errors in outpatient settings. August 22, 2009 Balkrishnan R, Foss CE, Pawaskar M, et al. Monitoring for medication errors in outpatient settings. J Dermatolog Treat. 2009;20(4):229-32. doi:10.1080/09546630802607487. https://psnet.ahrq.gov/issue/monitoring-medication-errors-outpatient-sett…

6825. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38919/psn-pdf
      January 28, 2011 - Setting priorities for patient safety: ethics, accountability, and public engagement. January 28, 2011 Pronovost P, Faden RR. Setting priorities for patient safety: ethics, accountability, and public engagement. JAMA. 2009;302(8):890-1. doi:10.1001/jama.2009.1177. https://psnet.ahrq.gov/issue/setting-priorities-pa…

6826. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39652/psn-pdf
      June 30, 2010 - Aftercare tips for patients checking out of the hospital. June 30, 2010 Alderman L. New York Times. June 18, 2010;B6. https://psnet.ahrq.gov/issue/aftercare-tips-patients-checking-out-hospital This news piece highlights efforts to improve discharge planning, enhance the safety of care transitions, and reduce readm…

6827. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35353/psn-pdf
      July 16, 2009 - Best-practice protocols: preventing adverse drug events. July 16, 2009 Weir VL. Best-practice protocols: preventing adverse drug events. Nurs Manage. 2005;36(9):24-30. https://psnet.ahrq.gov/issue/best-practice-protocols-preventing-adverse-drug-events This article reports on one hospital's use of failure modes and …

6828. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50768/psn-pdf
      December 27, 2019 - For example, payments could be linked to reducing disparities, which could encourage investment in cultural

6829. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33700/psn-pdf
      October 01, 2010 - that the public cares about, and I think that doctors and nurses care about, is making care better, reducing

6830. The Ongoing Journey to Prevent Patient Falls | PSNet
      psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
      December 18, 2024 - the day-to-day workflow, leadership support and an organizational culture of safety is important to reducing

6831. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. | PSNet
      psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
      January 23, 2017 - Reducing the risk of harm from medication errors in children.

6832. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35891/psn-pdf
      May 03, 2006 - Costs and Benefits of Health Information Technology. May 3, 2006 Shekelle PG, Morton SC, Keeler EB. Rockville, MD: Agency for Healthcare Research and Quality; April 2006. AHRQ Publication No. 06-E006. https://psnet.ahrq.gov/issue/costs-and-benefits-health-information-technology The authors reviewed the literature …

6833. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36948/psn-pdf
      September 09, 2011 - Errors in a stat laboratory: changes in type and frequency since 1996. September 9, 2011 Carraro P, Plebani M. Errors in a stat laboratory: types and frequencies 10 years later. Clin Chem. 2007;53(7):1338-42. https://psnet.ahrq.gov/issue/errors-stat-laboratory-changes-type-and-frequency-1996 The investigators con…

6834. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42596/psn-pdf
      October 23, 2013 - Diagnostic Errors and Strategies to Minimize Them. October 23, 2013 Cutrer WB, Sullivan WM, Fleming AE, et al. Curr Probl Pediatr Adolesc Health Care. 2013;43:225-257.   https://psnet.ahrq.gov/issue/diagnostic-errors-and-strategies-minimize-them Articles in this special issue cover diagnostic errors, includin…

6835. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39484/psn-pdf
      April 28, 2010 - Surgical fires, a clear and present danger. April 28, 2010 Yardley IE, Donaldson LJ. Surgical fires, a clear and present danger. Surgeon. 2010;8(2):87-92. doi:10.1016/j.surge.2010.01.005. https://psnet.ahrq.gov/issue/surgical-fires-clear-and-present-danger This article reviews the literature on surgical fires and …

6836. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40937/psn-pdf
      November 16, 2011 - AHRQ Projects to Prevent Healthcare-Associated Infections, Fiscal Year 2011. November 16, 2011 Rockville, MD: Agency for Healthcare Research and Quality; October 2011. AHRQ Publication No. 09- P013-4-E. https://psnet.ahrq.gov/issue/ahrq-projects-prevent-healthcare-associated-infections-fiscal-year-2011 This annou…

6837. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34002/psn-pdf
      March 17, 2011 - Utah DoH Patient Safety Initiatives. March 17, 2011 Center for Health Data, Utah Department of Health, PO Box 144004, Salt Lake City, UT 84114. https://psnet.ahrq.gov/issue/utah-doh-patient-safety-initiatives Utah established a number of collaborative initiatives to understand the nature and occurrence of adverse …

6838. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38709/psn-pdf
      June 17, 2009 - Enteral feeding misconnections: an update. June 17, 2009 Guenter P, Hicks RW, Simmons D. Enteral feeding misconnections: an update. Nutr Clin Pract. 2009;24(3):325-34. doi:10.1177/0884533609335174. https://psnet.ahrq.gov/issue/enteral-feeding-misconnections-update This review surveys information on enteral nutriti…

6839. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50601/psn-pdf
      October 09, 2022 - Medication Safety: Advancing the Development of Improvement Strategies and Tools (R18). October 9, 2022  Rockville, MD: Agency for Healthcare Research and Quality; September 28, 2022. PA- 20-028. https://psnet.ahrq.gov/issue/medication-safety-advancing-development-improvement Medication errors are …

6840. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36793/psn-pdf
      August 26, 2011 - Patient safety in Taiwan: a survey on orthopedic surgeons. August 26, 2011 Yang C-T, Chen H-H, Hou S-M. Patient safety in Taiwan: a survey on orthopedic surgeons. J Formos Med Assoc. 2007;106(3):212-6. https://psnet.ahrq.gov/issue/patient-safety-taiwan-survey-orthopedic-surgeons The researchers surveyed Taiwanese…