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7241. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846765/psn-pdf
      March 29, 2023 - Addressing Medical Gaslighting to Improve Maternal Health—Together. March 29, 2023 Oregon Patient Safety Commission: 2023. https://psnet.ahrq.gov/issue/addressing-medical-gaslighting-improve-maternal-health-together Gaslighting has been identified as a contributor to maternal mortality and morbidity. This toolkit …

7242. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61052/psn-pdf
      April 01, 2019 - Inadvertent Administration of an Oral Liquid Medicine into a Vein. April 1, 2019 Farnborough, UK; Healthcare Safety Investigation Branch: April 2019. https://psnet.ahrq.gov/issue/inadvertent-administration-oral-liquid-medicine-vein Wrong route medication administration is a never event. This report examined the co…

7243. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41931/psn-pdf
      December 19, 2012 - Preventing wrong-site surgery in Minnesota: a 5-year journey. December 19, 2012 Rydrych D, Apold J, Harder K. Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34. https://psnet.ahrq.gov/issue/preventing-wrong-site-surgery-minnesota-5-year-journey Discussing a 5-year effort to report, analyze, and red…

7244. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45462/psn-pdf
      August 31, 2016 - Learning From Mistakes. August 31, 2016 London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764. https://psnet.ahrq.gov/issue/learning-mistakes The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the…

7245. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45638/psn-pdf
      January 01, 2019 - Measures to improve diagnostic safety in clinical practice. November 2, 2016 Singh H, Graber ML, Hofer TP. Measures to Improve Diagnostic Safety in Clinical Practice. J Patient Saf. 2019;15(4):311-316. doi:10.1097/PTS.0000000000000338. https://psnet.ahrq.gov/issue/measures-improve-diagnostic-safety-clinical-practic…

7246. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42370/psn-pdf
      June 19, 2013 - Resident Projects for Improvement. June 19, 2013 Heilman J, ed. UNM CIR Journal of Quality Improvement in Healthcare. Albuquerque, NM: University of New Mexico; May 2013. https://psnet.ahrq.gov/issue/journal-quality-improvement-healthcare-second-edition This publication outlines quality and safety improvement proj…

7247. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45237/psn-pdf
      June 15, 2016 - Medication reconciliation in oncological patients: a randomized clinical trial. June 15, 2016 Vega TG-C, Sierra-Sánchez JF, Martínez-Bautista MJ, et al. Medication Reconciliation in Oncological Patients: A Randomized Clinical Trial. J Manag Care Spec Pharm. 2016;22(6):734-40. doi:10.18553/jmcp.2016.15248. https:/…

7248. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40204/psn-pdf
      April 14, 2011 - Residents' intentions and actions after patient safety education. April 14, 2011 Jansma JD, Wagner C, Bijnen AB. Residents' intentions and actions after patient safety education. BMC Health Serv Res. 2010;10:350. doi:10.1186/1472-6963-10-350. https://psnet.ahrq.gov/issue/residents-intentions-and-actions-after-pati…

7249. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45646/psn-pdf
      November 23, 2016 - Patient safety in the emergency department. November 23, 2016 Farmer B. Patient Safety in the Emergency Department. Emerg Med (N Y). 2016;48(9). doi:10.12788/emed.2016.0052. https://psnet.ahrq.gov/issue/patient-safety-emergency-department Emergency departments are high-risk environments due to the urgency of care …

7250. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42951/psn-pdf
      September 16, 2014 - Novel approach to cardiac alarm management on telemetry units. September 16, 2014 Whalen DA, Covelle PM, Piepenbrink JC, et al. Novel approach to cardiac alarm management on telemetry units. J Cardiovasc Nurs. 2014;29(5):E13-22. doi:10.1097/JCN.0000000000000114. https://psnet.ahrq.gov/issue/novel-approach-cardiac-…

7251. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42460/psn-pdf
      July 31, 2013 - Effectiveness of the surgical safety checklist in a high standard care environment. July 31, 2013 Lübbeke A, Hovaguimian F, Wickboldt N, et al. Effectiveness of the surgical safety checklist in a high standard care environment. Med Care. 2013;51(5):425-9. doi:10.1097/MLR.0b013e31828d1489. https://psnet.ahrq.gov/is…

7252. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37359/psn-pdf
      January 02, 2017 - Case study: preventing surgical complications at Baystate Medical Center. January 2, 2017 Fitzgerald J, Kanter G, Benjamin EM. Case Study: Preventing Surgical Complications at Baystate Medical Center. The Joint Commission Journal on Quality and Patient Safety. 2016;33(11). doi:10.1016/s1553- 7250(07)33076-6. http…

7253. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46596/psn-pdf
      November 01, 2017 - Infection prevention and control in pediatric ambulatory settings. November 1, 2017 Rathore MH, Jackson MA, AAP Committee on Infections Diseases. Pediatrics. 2017;140(5):e20172857. https://psnet.ahrq.gov/issue/infection-prevention-and-control-pediatric-ambulatory-settings Patient safety in the ambulatory environme…

7254. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73480/psn-pdf
      December 17, 2024 - Improving Patient Safety with Human Factors Methods. December 17, 2024 Armstrong Institute for Patient Safety and Quality, Baltimore, MD. April 17-18, 2025. https://psnet.ahrq.gov/issue/improving-patient-safety-human-factors-methods Human factors engineering (HFE) is a primary strategy for advancing safety in healt…

7255. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46494/psn-pdf
      January 24, 2018 - Complications. January 24, 2018 Anaesthesia. 2018;73(suppl 1):3-101. https://psnet.ahrq.gov/issue/complications Study of complications can provide insights into presurgical patient counseling, risk assessment, and medical harm prevention. Articles in this special issue explore complications in anesthesia, includin…

7256. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41683/psn-pdf
      September 19, 2012 - Techniques to improve patient safety in hospitals: what nurse administrators need to know. September 19, 2012 Fagan MJ. Techniques to improve patient safety in hospitals: what nurse administrators need to know. J Nurs Adm. 2012;42(9):426-430. doi:10.1097/NNA.0b013e3182664df5. https://psnet.ahrq.gov/issue/technique…

7257. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41083/psn-pdf
      December 12, 2012 - Teams under pressure in the emergency department: an interview study. December 12, 2012 Flowerdew L, Brown R, Russ S, et al. Teams under pressure in the emergency department: an interview study. Emerg Med J. 2012;29(12):e2. doi:10.1136/emermed-2011-200084. https://psnet.ahrq.gov/issue/teams-under-pressure-emergenc…

7258. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73872/psn-pdf
      September 22, 2021 - Parenteral nutrition safety. September 22, 2021 Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20. https://psnet.ahrq.gov/issue/parenteral-nutrition-safety Parenteral nutrition (PN) processes contain various steps that are prone to errors resulting in patient harm. This article discusses …

7259. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/860400/psn-pdf
      January 10, 2024 - AHA Patient Safety Initiative. January 10, 2024 American Hospital Association. https://psnet.ahrq.gov/issue/aha-patient-safety-initiative Leadership at the organization and system level is crucial to gaining improvement traction and sustainability. This initiative centers on safety culture, care inequities, and wo…

7260. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40403/psn-pdf
      August 25, 2011 - The quality and economic impact of disruptive behaviors on clinical outcomes of patient care. August 25, 2011 Rosenstein AH. The quality and economic impact of disruptive behaviors on clinical outcomes of patient care. Am J Med Qual. 2011;26(5):372-9. doi:10.1177/1062860611400592. https://psnet.ahrq.gov/issue/qual…