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101. Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax | PSNet
     psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
     December 14, 2022 - Users may contribute by submitting a case at the following link:  https://psnet.ahrq.gov/webmm/submit-case … BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation Submit

102. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35239/psn-pdf
     August 02, 2023 - American Hospital Association–McKesson Quest for Quality Prize. August 2, 2023 American Hospital Association. https://psnet.ahrq.gov/issue/american-hospital-association-mckesson-quest-quality-prize-1 This award program recognizes organization-wide commitment to five key goals that support high-quality health care…

103. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35632/psn-pdf
     February 03, 2025 - Anesthesia Patient Safety Foundation (APSF) Grant Program. February 3, 2025 Anesthesia Patient Safety Foundation. https://psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation-apsf-grant-program This grant program supports research that seeks to improve anesthesia safety and the development of researchers in …

104. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38375/psn-pdf
     December 01, 2019 - ISMP QuarterWatch Reports. April 17, 2019 Horsham, PA: Institute for Safe Medication Practices. https://psnet.ahrq.gov/issue/ismp-quarterwatch-reports This website provides quarterly reports that identify and analyze new risks related to medications and adverse drug events submitted to the Food and Drug Administra…

105. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50850/psn-pdf
     January 29, 2020 - Better Safer Care Victoria. January 29, 2020 Safer Care Victoria and Victorian Agency for Health Information. https://psnet.ahrq.gov/issue/better-safer-care-victoria Large scale tracking of adverse care incidents offers evidence that governments and organizations can use to target care process improvement efforts.…

106. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74142/psn-pdf
     January 02, 2024 - Robert L. Wears Patient Safety Leadership Award. November 1, 2023 Regional Center at Jacksonville University, University of Florida College of Medicine – Jacksonville, FL. https://psnet.ahrq.gov/issue/robert-l-wears-patient-safety-leadership-award Inspired by the research and leadership of Dr. Robert Wears, this aw…

107. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46863/psn-pdf
     December 05, 2024 - Safer Together Annual Report. December 5, 2024 Child Health Patient Safety Organization. Washington, DC: Children's Hospital Association. https://psnet.ahrq.gov/issue/perfecting-detection-understanding-source-harm This annual publication provides common cause analyses of incidents submitted to a pediatric patient …

108. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36110/psn-pdf
     April 04, 2024 - Sentinel Event Data Summary. April 4, 2024 Joint Commission. https://psnet.ahrq.gov/issue/sentinel-event-statistics-1995-2019 This website provides sentinel event data reported to The Joint Commission, which includes information on sentinel events reported from January through December 2023. Falls, wrong surgery a…

109. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60162/psn-pdf
     March 25, 2020 - Patient Safety Improvement Act of 2020. March 25, 2020 SB 3380. 116th Congress (2020). https://psnet.ahrq.gov/issue/patient-safety-improvement-act-2020 This bill submits amendments to existing US federal law to strengthen state-organized efforts to improve health care-associated infection control efforts, pediatri…

110. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43790/psn-pdf
     October 23, 2023 - Complaints to the Parliamentary and Health Service Ombudsman. October 23, 2023 Manchester, UK: Parliamentary and Health Service Ombudsman. https://psnet.ahrq.gov/issue/complaints-about-acute-trusts-2016-2017 The National Health Service broadly reports the results of system-level analyses and investigations into t…

111. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/863764/psn-pdf
     March 06, 2024 - Medication errors 2023: the year in review: January through December. March 6, 2024 Pharmacy Practice News; February 2024: Suppl 1-12. https://psnet.ahrq.gov/issue/medication-errors-2023-year-review-january-through-december The medication process has multiple steps in it that can open the door to mistakes. This ar…

112. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48026/psn-pdf
     July 10, 2019 - Network of Patient Safety Databases. July 10, 2019 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/network-patient-safety-databases The Patient Safety Organization (PSO) program seeks to gather and analyze nonidentifiable patient safety incident data to track concerns and reduce risks. Thi…

113. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46708/psn-pdf
     February 08, 2023 - FDA/ISMP Safe Medication Management Fellowship Program. February 8, 2023 Food and Drug Administration, Institute for Safe Medication Practices. https://psnet.ahrq.gov/issue/fdaismp-safe-medication-management-fellowship-program This fellowship program provides clinicians with learning opportunities at the Institute…

114. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50719/psn-pdf
     December 04, 2019 - A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! December 4, 2019 ISMP Medication Safety Alert! Acute Care Edition. November 7, 2019 https://psnet.ahrq.gov/issue/lot-happens-when-you-report-hazard-or-error-ismp-theres-no-black-hole-here The reporting and analysis of incidents i…

115. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35665/psn-pdf
     March 18, 2010 - Clear liquids may place patients at risk. March 18, 2010 Pennsylvania Patient Safety Reporting System. https://psnet.ahrq.gov/issue/clear-liquids-may-place-patients-risk Using reports submitted to the Pennsylvania Patient Safety Reporting System, this advisory cautions against using unlabeled clear liquids and pro…

116. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35919/psn-pdf
     January 01, 2019 - Pennsylvania Patient Safety Advisory. August 9, 2017 Patient Safety Authority https://psnet.ahrq.gov/issue/pennsylvania-patient-safety-advisory This quarterly newsletter shares insights and analysis on incident reports submitted through the Pennsylvania Patient Safety Reporting System. In 2019 this open-access pub…

117. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43202/psn-pdf
     September 11, 2023 - ISMP Survey on High-Alert Medications in Acute Care Settings. September 11, 2023 Plymouth Meeting, PA: Institute for Safe Medication Practices; 2023. https://psnet.ahrq.gov/issue/ismp-survey-high-alert-medications-acute-care-settings Experience from the sharp end helps to inform safety improvement initiatives. The…

118. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60855/psn-pdf
     August 26, 2020 - The paradoxes of defensive medicine. August 26, 2020 Saks MJ, Landsman S. Health Matrix: J Law-Med. 2020;30(1):25-84. https://psnet.ahrq.gov/issue/paradoxes-defensive-medicine Defensive medicine behaviors seeking to avoid malpractice risk due to care omissions challenge patient safety and value narratives. This le…

119. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/845653/psn-pdf
     March 08, 2023 - Examples of Medical Device Misconnections. March 8, 2023 Food and Drug Administration. February 23. 2023. https://psnet.ahrq.gov/issue/examples-medical-device-misconnections Mismatches of medical device connectors are known factors in therapeutic agent administration failures, despite efforts to redesign equipment…

120. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/856640/psn-pdf
     November 29, 2023 - Research from webAIRS incident reporting system. November 29, 2023 Anaesth Intensive Care. 2023;51(6):372-421. https://psnet.ahrq.gov/issue/research-webairs-incident-reporting-system Centralized de-identified reports of patient safety events serve a core purpose for learning and improvement. This article collectio…