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121. 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…

122. 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…

123. 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…

124. 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…

125. 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…

126. 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…

127. 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…

128. 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 …

129. 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…

130. 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…

131. 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…

132. 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…

133. 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…

134. 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…

135. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-463
     October 30, 2024 - The biggest barrier to reporting in both periods was the amount of time it took to submit a report.

136. 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…

137. 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…

138. 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…

139. 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…

140. 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…