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psnet.ahrq.gov/periodic-issue/periodic-issue-302July 28, 2021 - July 28, 2021 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports, …
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/848041/psn-pdfApril 26, 2023 - Potentiality of algorithms and artificial intelligence adoption to improve medication management in primary care: a systematic review. April 26, 2023 Damiani G, Altamura G, Zedda M, et al. Potentiality of algorithms and artificial intelligence adoption to improve medication management in primary care: a systematic… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/841475/psn-pdfJanuary 01, 2023 - The second victim of unanticipated adverse events. December 14, 2022 Chen S, Skidmore S, Ferrigno BN, et al. The second victim of unanticipated adverse events. J Thorac Cardiovasc Surg. 2023;166(3):890-894. doi:10.1016/j.jtcvs.2022.09.010. https://psnet.ahrq.gov/issue/second-victim-unanticipated-adverse-events “Se… -
psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriateJune 24, 2020 - SPOTLIGHT CASE Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. Citation Text: Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37132/psn-pdfJune 14, 2011 - Preventing medication errors in community pharmacy: root-cause analysis of transcription errors. June 14, 2011 Knudsen P, Herborg H, Mortensen AR, et al. Preventing medication errors in community pharmacy: root- cause analysis of transcription errors. Qual Saf Health Care. 2007;16(4):285-90. https://psnet.ahrq.gov… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73530/psn-pdfJuly 28, 2021 - The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: the QUMwatch study. July 28, 2021 Adie K, Fois RA, McLachlan AJ, et al. The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: T… -
psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negativeApril 27, 2022 - SPOTLIGHT CASE Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome Citation Text: Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome. PSNet [internet…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43366/psn-pdfMarch 04, 2015 - Safety of medication use in primary care. March 4, 2015 Olaniyan JO, Ghaleb M, Dhillon S, et al. Safety of medication use in primary care. Int J Pharm Pract. 2015;23(1):3-20. doi:10.1111/ijpp.12120. https://psnet.ahrq.gov/issue/safety-medication-use-primary-care This systematic review found that incidence rates of… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866692/psn-pdfSeptember 11, 2024 - Relationships between medications used in a mental health hospital and types of medication errors: a cross- sectional study over an 8-year period. September 11, 2024 Lebas R, Calvet B, Schadler L, et al. Relationships between medications used in a mental health hospital and types of medication errors: a cross-sect… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/843234/psn-pdfJanuary 01, 2013 - Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. February 1, 2023 Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive D… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836829/psn-pdfMarch 30, 2022 - Safety in fragile, conflict-affected, and vulnerable settings: An evidence scanning approach for identifying patient safety interventions. March 30, 2022 O’Brien N, Shaw A, Flott K, et al. Safety in fragile, conflict-affected, and vulnerable settings: an evidence scanning approach for identifying patient safety in… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837677/psn-pdfJuly 13, 2022 - Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia. July 13, 2022 Washington, DC: VA Office of the Inspector General; June 28, 2022. Report No 21-03349-186. https://psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-… -
psnet.ahrq.gov/perspective/conversation-derek-feeleyApril 10, 2024 - How do you prevent organizations from instinctively doing the wrong thing by forgetting these messy stages … DF : You have to require the messy stages. This wasn't achieved overnight.
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41541/psn-pdfSeptember 26, 2012 - Failures in communication and information transfer across the surgical care pathway: interview study. September 26, 2012 Nagpal K, Arora S, Vats A, et al. Failures in communication and information transfer across the surgical care pathway: interview study. BMJ Qual Saf. 2012;21(10):843-9. https://psnet.ahrq.gov/is… -
psnet.ahrq.gov/issue/patient-safety-climate-strength-concept-requires-more-attentionMarch 04, 2011 - Study Patient safety climate strength: a concept that requires more attention. Citation Text: Ginsburg LR, Oore DG. Patient safety climate strength: a concept that requires more attention. BMJ Qual Saf. 2016;25(9):680-7. doi:10.1136/bmjqs-2015-004150. Copy Citation Format: …
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39124/psn-pdfFebruary 18, 2011 - Adverse drug event rates in six community hospitals and the potential impact of computerized physician order entry for prevention. February 18, 2011 Hug BL, Witkowski DJ, Sox CM, et al. Adverse Drug Event Rates in Six Community Hospitals and the Potential Impact of Computerized Physician Order Entry for Prevention… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72836/psn-pdfJanuary 26, 2021 - PAM is used to determine level of patient activation and assess which of four stages the patient is -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/848358/psn-pdfMay 03, 2023 - Identifying electronic health record contributions to diagnostic error in ambulatory settings through legal claims analysis. May 3, 2023 Krevat S, Samuel S, Boxley C, et al. Identifying electronic health record contributions to diagnostic error in ambulatory settings through legal claims analysis. JAMA Netw Open. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837793/psn-pdfAugust 10, 2022 - The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study. August 10, 2022 Klopotowska JE, Kuks PFM, Wierenga PC, et al. The effect of structured medication review f… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47935/psn-pdfApril 17, 2019 - Teaching patient safety in global health: lessons from the Duke Global Health Patient Safety Fellowship. April 17, 2019 Johnston BE, Lou-Meda R, Mendez S, et al. Teaching patient safety in global health: lessons from the Duke Global Health Patient Safety Fellowship. BMJ Glob Health. 2019;4(1). doi:10.1136/bmjgh-201…
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