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121. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/864385/psn-pdf
     April 05, 2024 - Common Formats for Patient Safety Data Collection. March 13, 2024 Agency for Healthcare Research and Quality. Fed Register. Mar 6, 2024;89(45);15992. https://psnet.ahrq.gov/issue/common-formats-patient-safety-data-collection A standard system for voluntary reporting to patient safety organizations improves measurem…

122. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867758/psn-pdf
     March 12, 2025 - Errors in the EMR: under-recognized hazard for AI in healthcare. March 12, 2025 Morreim EH. Errors in the EMR: under-recognized hazard for AI in healthcare. Hous J Health Law Policy. 2025;24:127-165. https://psnet.ahrq.gov/issue/errors-emr-under-recognized-hazard-ai-healthcare Artificial intelligence (AI) systems…

123. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866169/psn-pdf
     June 19, 2024 - Safe and equitable pediatric clinical use of AI. June 19, 2024 Handley JL, Lehmann CU, Ratwani RM. Safe and equitable pediatric clinical use of AI. JAMA Pediatr. 2024;178(7):637-638. doi:10.1001/jamapediatrics.2024.0897. https://psnet.ahrq.gov/issue/safe-and-equitable-pediatric-clinical-use-ai Accepting shared res…

124. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41939/psn-pdf
     February 11, 2014 - The role of the electronic health record in patient safety events. February 11, 2014 Sparnon E, Marella WM. Pa Patient Saf Advis 2012 Dec;9(4):113-21. https://psnet.ahrq.gov/issue/role-electronic-health-record-patient-safety-events This piece analyzes data submitted to the Pennsylvania Patient Safety Reporting Sys…

125. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42845/psn-pdf
     December 18, 2014 - Breakdowns in the medication reconciliation process. December 18, 2014 Gao T, Gaunt MJ. PA-PSRS Patient Saf Advis. December 2013;10:125-136. https://psnet.ahrq.gov/issue/breakdowns-medication-reconciliation-process Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies …

126. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40833/psn-pdf
     October 05, 2011 - Personal best. October 5, 2011 Gawande A. New Yorker. October 3, 2011. https://psnet.ahrq.gov/issue/personal-best This magazine article explores the role of coaches in helping high-performing professionals, such as musicians and athletes, improve their performance. By submitting to observation in the operating roo…

127. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42108/psn-pdf
     March 13, 2013 - Distractions and their impact on patient safety. March 13, 2013 Feil M. PA-PSRS Patient Saf Advis. March 2013;10:1-10. https://psnet.ahrq.gov/issue/distractions-and-their-impact-patient-safety Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece outlines the types of distraction…

128. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37009/psn-pdf
     March 18, 2010 - Doing the "right" things to correct wrong-site surgery. March 18, 2010 Patient Safety Advisory https://psnet.ahrq.gov/issue/doing-right-things-correct-wrong-site-surgery This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results of other studies, and provides suggesti…

129. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/848828/psn-pdf
     May 10, 2023 - Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2023. May 10, 2023 118th Cong (2023-2024). https://psnet.ahrq.gov/issue/nurse-staffing-standards-hospital-patient-safety-and-quality-care-act-2023 Nurse staffing and patient care outcomes are linked, yet variation exists in nursing covera…

130. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47635/psn-pdf
     April 03, 2019 - Exploring vulnerability to patient safety events along the age continuum. April 3, 2019 Field C, Finley E, Deutsch ES. PA-PSRS Pa Patient Saf Advis. 2019;16(1). https://psnet.ahrq.gov/issue/exploring-vulnerability-patient-safety-events-along-age-continuum This article analyzed 2017 data submitted to the Pennsylvan…

131. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/855440/psn-pdf
     November 15, 2023 - NPSD Data Spotlight: Patterns of Fall Interventions. November 15, 2023 Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23- 0055. https://psnet.ahrq.gov/issue/npsd-data-spotlight-patterns-fall-interventions Falls are a frequently reported sentinel event. This Data Spo…

132. 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…

133. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39189/psn-pdf
     April 16, 2018 - Neuromuscular blocking agents: reducing associated wrong-drug errors. April 16, 2018 https://psnet.ahrq.gov/issue/neuromuscular-blocking-agents-reducing-associated-wrong-drug-errors This article discusses adverse incidents submitted to the Pennsylvania reporting system involving neuromuscular blocking agents and s…

134. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36123/psn-pdf
     January 05, 2017 - Medication errors involving neuromuscular blocking agents. January 5, 2017 Santell JP. Medication errors involving neuromuscular blocking agents. Jt Comm J Qual Patient Saf. 2006;32(8):470-5, 417. https://psnet.ahrq.gov/issue/medication-errors-involving-neuromuscular-blocking-agents The author analyzes error data…

135. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39835/psn-pdf
     December 27, 2018 - Advancement toward High Reliability in Healthcare Awards. December 27, 2018 Department of Defense Patient Safety Program; DoD PSP; DoD https://psnet.ahrq.gov/issue/advancement-toward-high-reliability-healthcare-awards This award recognizes outstanding high reliability improvement work in the Military Health System…

136. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/842432/psn-pdf
     January 11, 2023 - Medication errors: the year in review: January through December 2021. January 11, 2023 Pharmacy Practice News Special Edition. December 13, 2022: 43-54. https://psnet.ahrq.gov/issue/medication-errors-year-review-january-through-december-2021 Medication errors continue to occur despite long-standing efforts to redu…

137. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50838/psn-pdf
     January 29, 2020 - Start the new year off right by preventing these top 10 medication errors and hazards. January 29, 2020 ISMP Medication Safety Alert! Acute care edition. January 16, 2020;26(2):1-6. https://psnet.ahrq.gov/issue/start-new-year-right-preventing-these-top-10-medication-errors-and-hazards Medication errors routinely c…

138. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47803/psn-pdf
     October 07, 2021 - Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples. October 7, 2021 US Food and Drug Administration. October 7, 2021. https://psnet.ahrq.gov/issue/letter-health-care-providers-safe-use-surgical-staplers-and-staples Errors of commission during complex procedures can contribute to patient har…

139. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37285/psn-pdf
     December 24, 2007 - Safer Care for the Acutely Ill Patient: Learning from Serious Incidents. December 24, 2007 Thomson R, Luettel D, Healey F, Scobie S. London, England: National Patient Safety Agency; 2007. ISBN 9780955634055. https://psnet.ahrq.gov/issue/safer-care-acutely-ill-patient-learning-serious-incidents In analyzing inform…

140. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36352/psn-pdf
     April 14, 2011 - Patient expectations of fair complaint handling in hospitals: empirical data. April 14, 2011 Friele RD, Sluijs EM. Patient expectations of fair complaint handling in hospitals: empirical data. BMC Health Serv Res. 2006;6:106. https://psnet.ahrq.gov/issue/patient-expectations-fair-complaint-handling-hospitals-empir…