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9341. Learning from incidents in healthcare: the journey, not the arrival, matters. | PSNet
      psnet.ahrq.gov/issue/learning-incidents-healthcare-journey-not-arrival-matters
      June 12, 2024 - Commentary Learning from incidents in healthcare: the journey, not the arrival, matters. Citation Text: Leistikow I, Mulder S, Vesseur J, et al. Learning from incidents in healthcare: the journey, not the arrival, matters. BMJ Qual Saf. 2017;26(3):252-256. doi:10.1136/bmjqs-2015-004853. …

9342. Prescription Opioids: Medicare Needs to Expand Oversight Efforts to Reduce the Risk of Harm. | PSNet
      psnet.ahrq.gov/issue/prescription-opioids-medicare-needs-expand-oversight-efforts-reduce-risk-harm
      December 06, 2017 - Book/Report Prescription Opioids: Medicare Needs to Expand Oversight Efforts to Reduce the Risk of Harm. Citation Text: Prescription Opioids: Medicare Needs to Expand Oversight Efforts to Reduce the Risk of Harm. Washington, DC: United States Government Accountability Office; October 201…

9343. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer. | PSNet
      psnet.ahrq.gov/issue/national-scorecard-rates-hospital-acquired-conditions-2010-2015-interim-data-national-efforts
      December 24, 2008 - Book/Report National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer. Citation Text: National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health C…

9344. Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. | PSNet
      psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-fiscal-2021
      October 12, 2022 - Book/Report Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. Citation Text: Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. Washington, DC: Veterans Affairs Office of Inspector General; 2…

9345. Identifying modifiable barriers to medication error reporting in the nursing home setting. | PSNet
      psnet.ahrq.gov/issue/identifying-modifiable-barriers-medication-error-reporting-nursing-home-setting
      March 10, 2011 - Study Identifying modifiable barriers to medication error reporting in the nursing home setting. Citation Text: Handler S, Perera S, Olshansky EF, et al. Identifying modifiable barriers to medication error reporting in the nursing home setting. J Am Med Dir Assoc. 2007;8(9):568-74. C…

9346. Are amended surgical pathology reports getting to the correct responsible care provider? | PSNet
      psnet.ahrq.gov/issue/are-amended-surgical-pathology-reports-getting-correct-responsible-care-provider
      September 04, 2024 - Study Are amended surgical pathology reports getting to the correct responsible care provider? Citation Text: Parkash V, Domfeh A, Cohen P, et al. Are amended surgical pathology reports getting to the correct responsible care provider? Am J Clin Pathol. 2014;142(1):58-63. doi:10.1309/AJC…

9347. Incidents and errors in neonatal intensive care: a review of the literature. | PSNet
      psnet.ahrq.gov/issue/incidents-and-errors-neonatal-intensive-care-review-literature
      June 15, 2011 - Review Incidents and errors in neonatal intensive care: a review of the literature. Citation Text: Snijders C, van Lingen RA, Molendijk A, et al. Incidents and errors in neonatal intensive care: a review of the literature. Arch Dis Child Fetal Neonatal Ed. 2007;92(5):F391-8. Copy Cit…

9348. Using computerized prescriber order entry to limit overrides from automated dispensing cabinets. | PSNet
      psnet.ahrq.gov/issue/using-computerized-prescriber-order-entry-limit-overrides-automated-dispensing-cabinets
      May 18, 2022 - Commentary Using computerized prescriber order entry to limit overrides from automated dispensing cabinets. Citation Text: Drake E, Srinivas P, Trujillo T. Using computerized prescriber order entry to limit overrides from automated dispensing cabinets. Am J Health-Syst Pharm. 2016;73(14)…

9349. Request for comments on the proposed measures and 2020 targets for the National Action Plan for Adverse Drug Event Prevention: inpatient and outpatient measures for reduction of adverse drug events from anticoagulants, diabetes agents, and opioid analgesics. | PSNet
      psnet.ahrq.gov/issue/request-comments-proposed-measures-and-2020-targets-national-action-plan-adverse-drug-event
      October 21, 2016 - Press Release/Announcement Request for comments on the proposed measures and 2020 targets for the National Action Plan for Adverse Drug Event Prevention: inpatient and outpatient measures for reduction of adverse drug events from anticoagulants, diabetes agents, and opioid analgesics. Cita…

9350. ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient Safety Collaborative. | PSNet
      psnet.ahrq.gov/issue/acgme-summary-report-pursuing-excellence-pathway-leaders-patient-safety-collaborative
      October 18, 2017 - Book/Report ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient Safety Collaborative. Citation Text: ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient Safety Collaborative. Passiment M, Wagner R, Weiss KB for the Pursuing Excellence in Clinical Learn…

9351. Building an ambulatory safety program at an academic health system. | PSNet
      psnet.ahrq.gov/issue/building-ambulatory-safety-program-academic-health-system
      April 22, 2016 - Commentary Building an ambulatory safety program at an academic health system. Citation Text: Desai S, Fiumara K, Kachalia A. Building an Ambulatory Safety Program at an Academic Health System. J Patient Saf. 2021;17(2):e84-e90. doi:10.1097/PTS.0000000000000594. Copy Citation Forma…

9352. When should a multicampus hospital be considered a single entity for public reporting on patient safety issues? | PSNet
      psnet.ahrq.gov/issue/when-should-multicampus-hospital-be-considered-single-entity-public-reporting-patient-safety
      June 28, 2011 - Commentary When should a multicampus hospital be considered a single entity for public reporting on patient safety issues? Citation Text: Naessens JM, Culbertson R, Lefante JJ, et al. When should a multicampus hospital be considered a single entity for public reporting on patient safet…

9353. New patient safety panel ready to focus on hospitals' reports of 'near misses.' | PSNet
      psnet.ahrq.gov/issue/new-patient-safety-panel-ready-focus-hospitals-reports-near-misses
      December 19, 2012 - Newspaper/Magazine Article New patient safety panel ready to focus on hospitals' reports of 'near misses.' Citation Text: Freeman L. Copy Citation Save Print Share Facebook Twitter Linkedin Copy URL Jan…

9354. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46725/psn-pdf
      April 11, 2018 - Are we missing the near misses in the OR? Underreporting of safety incidents in pediatric surgery. April 11, 2018 Hamilton EC, Pham DH, Minzenmayer AN, et al. Are we missing the near misses in the OR?- underreporting of safety incidents in pediatric surgery. J Surg Res. 2018;221:336-342. doi:10.1016/j.jss.2017.08.…

9355. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837214/psn-pdf
      May 25, 2022 - Global Report on Infection Prevention and Control: Executive Summary. May 25, 2022 Geneva, Switzerland; World Health Organization; May 5, 2022. https://psnet.ahrq.gov/issue/global-report-infection-prevention-and-control-executive-summary Healthcare-acquired infection is a persistent systemic problem. This report r…

9356. 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…

9357. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46478/psn-pdf
      March 27, 2018 - Promote a culture of safety with good catch reports. March 27, 2018 Wallace SC, Mamrol C, Finley E. PA-PSRS Patient Saf Advis. September 2017;14. https://psnet.ahrq.gov/issue/promote-culture-safety-good-catch-reports Near misses or good catches present organizations with learning opportunities. Using data compariso…

9358. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46909/psn-pdf
      August 01, 2018 - Guidance on Safe Medical Staffing: Report of a Working Party. August 1, 2018 London, UK: Royal College of Physicians; 2018. ISBN: 9781860167270. https://psnet.ahrq.gov/issue/guidance-safe-medical-staffing-report-working-party Lack of appropriate staffing can diminish the safety and effectiveness of medical service…

9359. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43997/psn-pdf
      August 02, 2015 - Sentinel events, serious reportable events, and root cause analysis. August 2, 2015 Chen TC, Schein OD, Miller JW. Sentinel events, serious reportable events, and root cause analysis. JAMA Ophthalmol. 2015;133(6):631-632. doi:10.1001/jamaophthalmol.2015.0672. https://psnet.ahrq.gov/issue/sentinel-events-serious-re…

9360. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/862996/psn-pdf
      February 21, 2024 - Descriptive analysis on disproportionate medication errors and associated patient characteristics in the Food and Drug Administration's adverse event reporting system. February 21, 2024 Pera V, van Vaerenbergh F, Kors JA, et al. Descriptive analysis on disproportionate medication errors and associated patient cha…