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121. 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 …

122. 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…

123. 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…

124. 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…

125. 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…

126. 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…

127. 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…

128. 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…

129. 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…

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/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…

133. 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…

134. 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…

135. 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…

136. 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…

137. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37251/psn-pdf
     February 28, 2018 - Drug labeling and packaging — looking beyond what meets the eye. February 28, 2018 PA-PSRS Patient Safety Advisory. https://psnet.ahrq.gov/issue/drug-labeling-and-packaging-looking-beyond-what-meets-eye Drawing from data submitted to the Patient Safety Authority reporting system, this article documents factors in…

138. 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…

139. 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…

140. 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…