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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43122/psn-pdf
    April 08, 2018 - Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. April 8, 2018 Newman-Toker DE, Moy E, Valente E, et al. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Diagnosis (Berl). 201…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60909/psn-pdf
    September 16, 2020 - Improving patient handoffs and transitions through adaptation and implementation of I-PASS across multiple handoff settings. September 16, 2020 Blazin LJ, Sitthi-Amorn J, Hoffman JM, et al. Improving patient handoffs and transitions through adaptation and implementation of I-PASS across multiple handoff settings. …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855427/psn-pdf
    November 15, 2023 - Preventing nosocomial bloodstream infections (NBSIs) by implementing hospitalwide, department-level, self- investigations: a NBSIs frontline ownership intervention. November 15, 2023 Mudrik-Zohar H, Chowers M, Temkin E, et al. Preventing nosocomial bloodstream infections (NBSIs) by implementing hospitalwide, depar…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73600/psn-pdf
    August 18, 2021 - Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial. August 18, 2021 Blum MR, Sallevelt B, Spinewine A, et al. Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised contr…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44037/psn-pdf
    March 14, 2018 - Pediatric medication safety in the emergency department. March 14, 2018 Benjamin L, Frush K, Shaw KN, et al. Pediatric Medication Safety in the Emergency Department. Ann Emerg Med. 2018;71(3):e17-e24. doi:10.1016/j.annemergmed.2017.12.013. https://psnet.ahrq.gov/issue/pediatric-medication-safety-emergency-departmen…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73394/psn-pdf
    June 16, 2021 - Advanced medication reconciliation: a systematic review of the impact on medication errors and adverse drug events associated with transitions of care. June 16, 2021 Killin L, Hezam A, Anderson KK, et al. Advanced medication reconciliation: a systematic review of the impact on medication errors and adverse drug ev…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865706/psn-pdf
    May 01, 2024 - Stigmatizing language, patient demographics, and errors in the diagnostic process. May 1, 2024 Brooks KC, Raffel KE, Chia D, et al. Stigmatizing language, patient demographics, and errors in the diagnostic process. JAMA Intern Med. 2024;184(6):704-706. doi:10.1001/jamainternmed.2024.0705. https://psnet.ahrq.gov/is…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60846/psn-pdf
    January 01, 2021 - Safety climate associated with adverse events in nursing homes: a national VA study. August 26, 2020 Quach ED, Kazis LE, Zhao S, et al. Safety climate associated with adverse events in nursing homes: a national VA study. J Am Med Dir Assoc. 2021;22(2):388-392. doi:10.1016/j.jamda.2020.05.028. https://psnet.ahrq.go…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838325/psn-pdf
    October 12, 2022 - Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021. October 12, 2022 Washington, DC: VA Office of the Inspector General; September 15, 2022. Report no. 22-00815-232. https://psnet.ahrq.gov/issue/comprehensive-healthcare…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73688/psn-pdf
    September 08, 2021 - Effect of medication reconciliation on patient reported potential adverse events after hospital discharge. September 8, 2021 Stuijt CCM, Bekker CL, van den Bemt BJF, et al. Effect of medication reconciliation on patient reported potential adverse events after hospital discharge. Res Social Adm Pharm. 2021;17(8):142…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73280/psn-pdf
    May 19, 2021 - Rates of serious surgical errors in California and plans to prevent recurrence. May 19, 2021 Cohen AJ, Lui H, Zheng M, et al. Rates of serious surgical errors in California and plans to prevent recurrence. JAMA Netw Open. 2021;4(5):e217058. doi:10.1001/jamanetworkopen.2021.7058. https://psnet.ahrq.gov/issue/rates-…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61096/psn-pdf
    November 04, 2020 - Wrong drug and wrong dose dispensing errors identified in pharmacist professional liability claims. November 4, 2020 Reiner G, Pierce SL, Flynn J. J Am Pharm Assoc (2003). 2020;60(5):e50-e56. https://psnet.ahrq.gov/issue/wrong-drug-and-wrong-dose-dispensing-errors-identified-pharmacist- professional-liability Des…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47405/psn-pdf
    January 27, 2019 - Robotic dispensing improves patient safety, inventory management, and staff satisfaction in an outpatient hospital pharmacy. January 27, 2019 Rodriguez-Gonzalez CG, Herranz-Alonso A, Escudero-Vilaplana V, et al. Robotic dispensing improves patient safety, inventory management, and staff satisfaction in an outpatie…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72644/psn-pdf
    February 01, 2021 - Best Practices in Developing Proprietary Names for Human Nonprescription Drug Products. January 13, 2021 Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research; December 7, 2020.  https://psnet.ahrq.gov/issue/best-practices-developing-p…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43828/psn-pdf
    January 14, 2015 - Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals. January 14, 2015 ISMP Medication Safety Alert! Acute Care Edition. December 18, 2014;19:1,4. https://psnet.ahrq.gov/issue/tragic-error-neuromuscular-blocker-should-prompt-risk-assessment-all- hospitals This newsletter article …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46260/psn-pdf
    July 26, 2017 - ACOG Committee opinion #680: the use and development of checklists in obstetrics and gynecology. July 26, 2017 American College of Obstetricians and Gynecologists’ Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2016;128:e237-e240. https://psnet.ahrq.gov/issue/acog-committee-opinion-680-use-an…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837332/psn-pdf
    June 08, 2022 - Influence of psychological safety and organizational support on the impact of humiliation on trainee well- being. June 8, 2022 Appelbaum NP, Santen SA, Perera RA, et al. Influence of psychological safety and organizational support on the impact of humiliation on trainee well-being. J Patient Saf. 2022;18(4):370-37…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60927/psn-pdf
    September 16, 2020 - Amid COVID-19, discipline against bad doctors plummets; more medical errors may slip through cracks. September 16, 2020 O'Donnell J. USA Today. September 8, 2020 https://psnet.ahrq.gov/issue/amid-covid-19-discipline-against-bad-doctors-plummets-more-medical-errors- may-slip-through Management and clinical functio…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73912/psn-pdf
    October 06, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science. October 6, 2021 Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF. https://ps…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45798/psn-pdf
    February 01, 2017 - American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. February 1, 2017 Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll Surg. 2017;224(1):59-74. doi:10.…

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