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7121. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43491/psn-pdf
      January 01, 2015 - The systems approach to medicine: controversy and misconceptions. December 9, 2014 Dekker SWA, Leveson NG. The systems approach to medicine: controversy and misconceptions. BMJ Qual Saf. 2015;24(1):7-9. doi:10.1136/bmjqs-2014-003106. https://psnet.ahrq.gov/issue/systems-approach-medicine-controversy-and-misconcept…

7122. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42364/psn-pdf
      September 18, 2013 - The pursuit of better diagnostic performance: a human factors perspective. September 18, 2013 Henriksen K, Brady J. The pursuit of better diagnostic performance: a human factors perspective. BMJ Qual Saf. 2013;22(Suppl 2):ii1-ii5. doi:10.1136/bmjqs-2013-001827. https://psnet.ahrq.gov/issue/pursuit-better-diagnosti…

7123. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36039/psn-pdf
      March 02, 2011 - The effects of on-duty napping on intern sleep time and fatigue. March 2, 2011 Arora V, Dunphy C, Chang VY, et al. The effects of on-duty napping on intern sleep time and fatigue. Ann Intern Med. 2006;144(11):792-8. https://psnet.ahrq.gov/issue/effects-duty-napping-intern-sleep-time-and-fatigue The investigators …

7124. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41955/psn-pdf
      January 09, 2013 - Making Medical Devices Safer at Home. January 9, 2013 Consumer Updates. Silver Spring, MD: US Food and Drug Administration; December 12, 2012. https://psnet.ahrq.gov/issue/making-medical-devices-safer-home Highlighting concerns associated with patients' use of medical devices at home, such as difficulty understand…

7125. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50727/psn-pdf
      December 11, 2019 - Your diagnosis was wrong. Could doctor bias have been a factor? December 11, 2019 Glicksman E. Washington Post. November 17, 2019. https://psnet.ahrq.gov/issue/your-diagnosis-was-wrong-could-doctor-bias-have-been-factor Unconscious assumptions and biases are known contributors to poor decision-making. This news st…

7126. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46466/psn-pdf
      July 11, 2018 - Distinct newborn identification requirement. July 11, 2018 R3 Report. June 25, 2018;7:1-2. https://psnet.ahrq.gov/issue/distinct-newborn-identification-requirement Neonatal patients are at risk for misidentification due to communication challenges and lack of distinguishable features. This report highlights new Jo…

7127. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41411/psn-pdf
      October 19, 2012 - Minnesota Hospital Association Statewide Project: SAFE from FALLS. October 19, 2012 Apold J, Quigley PA. Minnesota Hospital Association Statewide Project: SAFE from FALLS. J Nurs Care Qual. 2012;27(4):299-306. doi:10.1097/NCQ.0b013e3182599d1b. https://psnet.ahrq.gov/issue/minnesota-hospital-association-statewide-p…

7128. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40696/psn-pdf
      December 01, 2011 - Rapid response systems: a prospective study of response times. December 1, 2011 Adelstein B-A, Piza MA, Nayyar V, et al. Rapid response systems: a prospective study of response times. J Crit Care. 2011;26(6):635.e11-8. doi:10.1016/j.jcrc.2011.03.013. https://psnet.ahrq.gov/issue/rapid-response-systems-prospective-…

7129. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40568/psn-pdf
      June 29, 2011 - Tubing misconnections: normalization of deviance. June 29, 2011 Simmons D, Symes L, Guenter P, et al. Tubing misconnections: normalization of deviance. Nutr Clin Pract. 2011;26(3):286-293. doi:10.1177/0884533611406134. https://psnet.ahrq.gov/issue/tubing-misconnections-normalization-deviance Analyzing published ca…

7130. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40668/psn-pdf
      March 04, 2015 - Body CT: technical advances for improving safety. March 4, 2015 Marin D, Nelson RC, Rubin GD, et al. Body CT: technical advances for improving safety. AJR Am J Roentgenol. 2011;197(1):33-41. doi:10.2214/AJR.11.6755. https://psnet.ahrq.gov/issue/body-ct-technical-advances-improving-safety This article explores risk…

7131. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41972/psn-pdf
      January 23, 2013 - Impact of a pharmacotherapy alerting system on medication errors. January 23, 2013 Natali BJ, Varkey AC, Garey KW, et al. Impact of a pharmacotherapy alerting system on medication errors. American Journal of Health-System Pharmacy. 2012;70(1). doi:10.2146/ajhp120126. https://psnet.ahrq.gov/issue/impact-pharmacothe…

7132. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39766/psn-pdf
      August 18, 2010 - Paediatric dosing errors before and after electronic prescribing. August 18, 2010 Jani Y, Barber N, Wong ICK. Paediatric dosing errors before and after electronic prescribing. Qual Saf Health Care. 2010;19(4):337-40. doi:10.1136/qshc.2009.033068. https://psnet.ahrq.gov/issue/paediatric-dosing-errors-and-after-elec…

7133. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73431/psn-pdf
      June 23, 2021 - Drive to Deprescribe. June 23, 2021 The Society for Post-Acute and Long-Term Care Medicine. https://psnet.ahrq.gov/issue/drive-deprescribe Polypharmacy is a known challenge to patient safety. This collective program encourages long-term care organizations, physicians, and pharmacists to take part in a learning net…

7134. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44436/psn-pdf
      October 30, 2017 - Overreaction. October 30, 2017 Shell ER. Overreaction. Scientific American. 2015;313(5):28-9. https://psnet.ahrq.gov/issue/overreaction Reporting on how test inaccuracies can lead to misdiagnosis of food allergies in children and the potential consequences, this magazine article describes a diagnostic tool to dete…

7135. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35382/psn-pdf
      October 05, 2005 - Rx for a better prescription. Hospital bans doctors from using confusing medical abbreviations. October 5, 2005 Hall J. Fredericksburg Times. September 25, 2005 https://psnet.ahrq.gov/issue/rx-better-prescription-hospital-bans-doctors-using-confusing-medical- abbreviations This article presents one hospital’s pro…

7136. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42344/psn-pdf
      September 24, 2016 - Strategies for preventing distractions and interruptions in the OR. September 24, 2016 Clark GJ. Strategies for preventing distractions and interruptions in the OR. AORN J. 2013;97(6):702-707. doi:10.1016/j.aorn.2013.01.018. https://psnet.ahrq.gov/issue/strategies-preventing-distractions-and-interruptions-or Dist…

7137. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42332/psn-pdf
      June 12, 2013 - Quality improvement through implementation of discharge order reconciliation. June 12, 2013 Lu Y, Clifford P, Bjorneby A, et al. Quality improvement through implementation of discharge order reconciliation. Am J Health Syst Pharm. 2013;70(9):815-20. doi:10.2146/ajhp120050. https://psnet.ahrq.gov/issue/quality-impr…

7138. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40903/psn-pdf
      March 08, 2015 - Does your patient really understand? March 8, 2015 Huff C. Does your patient really understand? Hospitals & health networks. 2011;85(10):34-5, 37-8, 2. https://psnet.ahrq.gov/issue/does-your-patient-really-understand This article discusses health literacy and describes an initiative to reduce gaps in understanding …

7139. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42753/psn-pdf
      November 20, 2013 - Dealing with a medical mistake: should physicians apologize to patients? November 20, 2013 Tabler NG Jr. https://psnet.ahrq.gov/issue/dealing-medical-mistake-should-physicians-apologize-patients This article discusses how apologies address patients' needs when a medical mistake has occurred and how such disclosur…

7140. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37704/psn-pdf
      April 23, 2008 - Decreasing paediatric prescribing errors in a district general hospital. April 23, 2008 Davey AL, Britland A, Naylor RJ. Decreasing paediatric prescribing errors in a district general hospital. Qual Saf Health Care. 2008;17(2):146-9. doi:10.1136/qshc.2006.021212. https://psnet.ahrq.gov/issue/decreasing-paediatric-…