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161. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867097/psn-pdf
     November 06, 2024 - Recommendations but no Action: Improving the Effectiveness of Quality and Safety Recommendations in Healthcare. November 6, 2024 Recommendations But No Action: Improving The Effectiveness Of Quality And Safety Recommendations In Healthcare. Dorset, UK: Health Services Safety Investigations Body; September 2024. h…

162. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866247/psn-pdf
     July 10, 2024 - Analysis of critical incident reports using natural language processing. July 10, 2024 Denecke K, Paula H. Analysis of critical incident reports using natural language processing. Stud Health Technol Inform. 2024;313:1-6. doi:10.3233/shti240002. https://psnet.ahrq.gov/issue/analysis-critical-incident-reports-using…

163. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/863765/psn-pdf
     March 06, 2024 - Patient safety and artificial intelligence in clinical care. March 6, 2024 Ratwani RM, Bates DW, Classen DC. Patient safety and artificial intelligence in clinical care. JAMA Health Forum. 2024;5(2):e235514. doi:10.1001/jamahealthforum.2023.5514. https://psnet.ahrq.gov/issue/patient-safety-and-artificial-intelligen…

164. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865482/psn-pdf
     April 03, 2024 - Impact of a relocation to a new critical care building on pediatric safety events. April 3, 2024 Furthmiller A, Sahay R, Zhang B, et al. Impact of a relocation to a new critical care building on pediatric safety events. J Hosp Med. 2024;19(5):589-595. doi:10.1002/jhm.13324. https://psnet.ahrq.gov/issue/impact-relo…

165. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42812/psn-pdf
     August 02, 2016 - Healthcare Practitioner’s Vaccine Error Reporting Form. August 2, 2016 Institute for Safe Medication Practices. https://psnet.ahrq.gov/issue/healthcare-practitioners-vaccine-error-reporting-form This form collects data on errors and concerns associated with vaccines as part of a national reporting program tracking…

166. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36828/psn-pdf
     August 29, 2011 - Pediatric medication errors in the postanesthesia care unit: analysis of MEDMARX data. August 29, 2011 Payne CH, Smith CR, Newkirk LE, et al. Pediatric medication errors in the postanesthesia care unit: analysis of MEDMARX data. AORN J. 2007;85(4):731-40; quiz 741-4. https://psnet.ahrq.gov/issue/pediatric-medicati…

167. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44802/psn-pdf
     April 01, 2021 - Overall Hospital Quality Star Ratings. April 1, 2021 Centers for Medicare & Medicaid Services. https://psnet.ahrq.gov/issue/overall-hospital-quality-star-ratings-overview Hospital rating programs have received significant public attention, but concerns have been raised regarding their usefulness. This website prov…

168. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73407/psn-pdf
     June 16, 2021 - Common Formats for Patient Safety Data Collection: Diagnostic Safety 0.1. June 16, 2021 The Agency for Healthcare Research and Quality. Fed Register. 2021;86(103): 29263-29264. https://psnet.ahrq.gov/issue/common-formats-patient-safety-data-collection-diagnostic-safety-01 Measurement of diagnostic errors is an imp…

169. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73075/psn-pdf
     March 24, 2021 - Analysis of transdermal medication patch errors uncovers a “patchwork” of safety challenges. March 24, 2021 ISMP Medication Safety Alert! Acute Care. March 11, 2021;26(5):1-6. https://psnet.ahrq.gov/issue/analysis-transdermal-medication-patch-errors-uncovers-patchwork-safety- challenges Skin patches are a conveni…

170. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/850176/psn-pdf
     June 07, 2023 - Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision. June 7, 2023 Grossman D, Joffe C, Kaller S, et al. Advancing New Standards in Reproductive Health, University of California, San Francisco; 2023. https://psnet.ahrq.gov/issue/care-post-roe-documenting-cases-poor-quality-care-dobbs-deci…

171. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44749/psn-pdf
     December 27, 2018 - Southern Baptist Hospital of Florida v. Charles. December 27, 2018 Fla Ct App, 1st Dist. October 28, 2015. https://psnet.ahrq.gov/issue/southern-baptist-hospital-florida-v-charles The Patient Safety and Quality Improvement Act (PSQIA) provides federal protection of adverse event reports voluntarily submitted to pa…

172. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60718/psn-pdf
     July 22, 2020 - First Do No Harm. The Report of the Independent Medicines and Medical Devices Safety Review. July 22, 2020 Cumberlege J. London, England, Crown Copyright. July 8, 2020. https://psnet.ahrq.gov/issue/first-do-no-harm-report-independent-medicines-and-medical-devices-safety- review Implicit biases are known to affect…

173. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45544/psn-pdf
     December 19, 2016 - Prescribing errors that cause harm. December 19, 2016 Rider BB, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. September 2016;13:81-91. https://psnet.ahrq.gov/issue/prescribing-errors-cause-harm Prescribing errors can have harmful results. Analyzing prescribing error reports submitted over a 12- year period, t…

174. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44550/psn-pdf
     September 30, 2015 - Infections associated with reprocessed flexible bronchoscopes. September 30, 2015 FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; September 17, 2015. https://psnet.ahrq.gov/issue/infections-associated-reprocessed-flexible-bronchoscopes Use of incompletely cleaned medical devices has b…

175. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47318/psn-pdf
     October 12, 2018 - ISMP Survey on IV Push Medication Practices. October 12, 2018 Institute for Safe Medication Practices; ISMP. https://psnet.ahrq.gov/issue/ismp-survey-iv-push-medication-practices Errors in IV push medication use can cause patient harm. This survey seeks to gather data on how clinicians administer IV push medicatio…

176. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43680/psn-pdf
     November 19, 2014 - FDA Pharmacists Help Consumers Use Medicines Safely. November 19, 2014 Silver Spring, MD: United States Food and Drug Administration; October 31, 2014. https://psnet.ahrq.gov/issue/fda-pharmacists-help-consumers-use-medicines-safely Studies have shown that pharmacist involvement can prevent medication errors. To he…

177. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866529/psn-pdf
     October 08, 2024 - HHS seeks input on Medical Office Survey on Patient Safety Culture Database information collection. October 8, 2024 HHS seeks input on Medical Office Survey on Patient Safety Culture Database information collection. Agency for Healthcare Quality and Research. Fed Register. October 02, 2024;89:80247-80249. https://…

178. The Duke Pediatric Residency Safety Council | PSNet
     psnet.ahrq.gov/innovation/duke-pediatric-residency-safety-council
     November 16, 2022 - Safety Council. 9 The study found that the percentage of residents who strongly agreed that they could submit … morbidity and mortality conferences, safety event report reviews, and training residents on how to submit

179. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837513/psn-pdf
     June 22, 2022 - Agency Information Collection Activities: Proposed Collection; Comment Request, "Hospital Survey on Patient Safety Culture Comparative Database.'' June 22, 2022 Agency for Healthcare Quality and Research. Fed Register. June 3, 2022;87: 33795-33796.  https://psnet.ahrq.gov/issue/agency-information-collection-a…

180. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/848382/psn-pdf
     May 03, 2023 - Events that inspired change: the importance of sharing what happened to stop it from happening again. May 3, 2023 Myers E, Allen C. Events that inspired change: the importance of sharing what happened to stop it from happening again. Patient Saf. 2023;5(1):62-63. doi:10.33940/001c.74079. https://psnet.ahrq.gov/iss…