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psnet.ahrq.gov/node/49552/psn-pdf
January 01, 2008 - Residents' suggestions for reducing errors in teaching hospitals. N Engl J Med.
2003;348:851-855.
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psnet.ahrq.gov/issue/hardwiring-safety-computer-system-one-hospitals-actions-provide-technology-support-u-500
February 24, 2016 - Newspaper/Magazine Article
Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin.
Citation Text:
Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin. ISMP Medicatio…
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psnet.ahrq.gov/node/33755/psn-pdf
September 01, 2013 - What We've Learned About Leveraging Leadership and
Culture to Affect Change and Improve Patient Safety
September 1, 2013
Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve
Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/what-weve-learned-ab…
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psnet.ahrq.gov/node/35314/psn-pdf
August 31, 2005 - The health factory.
August 31, 2005
Spear SJ.
https://psnet.ahrq.gov/issue/health-factory
In this editorial, the author suggests that health care organizations approach error the way other industries
do, by constantly evaluating and solving problems, rather than working around them.
https://psnet.ahrq.gov/issue/h…
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psnet.ahrq.gov/issue/selected-medication-safety-risks-manage-2016-might-otherwise-fall-radar-screen-part-1-and
March 09, 2016 - Newspaper/Magazine Article
Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2.
Citation Text:
Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2. ISMP Medicat…
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psnet.ahrq.gov/node/33910/psn-pdf
May 01, 2016 - Quick Tips—When Getting A Prescription.
May 1, 2016
Agency for Healthcare Research and Quality; AHRQ.
https://psnet.ahrq.gov/issue/quick-tips-when-getting-prescription
This Web site suggests questions that all patients should ask a physician, nurse, and/or pharmacist when
they receive a medication prescription.
h…
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psnet.ahrq.gov/node/38247/psn-pdf
June 27, 2018 - Debriefing for patient safety.
June 27, 2018
Turner SH, Kurtz WD. Patient Saf Qual Healthc. November/December 2008:5:42-44,46.
https://psnet.ahrq.gov/issue/debriefing-patient-safety
This article provides guidelines for effective clinical debriefings and suggests how to position these
conversations as learning oppo…
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psnet.ahrq.gov/node/36534/psn-pdf
March 09, 2009 - Standardizing hand-off processes.
March 9, 2009
Gregory BSC. Standardizing hand-off processes. AORN J. 2006;84(6):1059-61.
https://psnet.ahrq.gov/issue/standardizing-hand-processes
The author suggests ways to improve hand-off communications and provides an assessment form to assist
staff in detecting weaknesses in…
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psnet.ahrq.gov/issue/accelerating-uptake-safety-initiatives-and-guidelines-role-implementation-science
November 26, 2014 - February 8, 2006
Injectable Opioid Shortages: Suggestions for Management and Conservation
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psnet.ahrq.gov/issue/fourth-cause-campaign
April 22, 2009 - October 5, 2005
Injectable Opioid Shortages: Suggestions for Management and Conservation
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psnet.ahrq.gov/issue/reducing-patient-risk-prescription-instruction-errors-six-sigma-approach
October 17, 2012 - April 23, 2021
Injectable Opioid Shortages: Suggestions for Management and Conservation
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psnet.ahrq.gov/node/40299/psn-pdf
April 16, 2018 - Medication errors in the emergency department: need for
pharmacy involvement?
April 16, 2018
https://psnet.ahrq.gov/issue/medication-errors-emergency-department-need-pharmacy-involvement
This piece reports on the prevalence of medication errors in the emergency department and suggests
expanding pharmacy involvemen…
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psnet.ahrq.gov/node/40525/psn-pdf
June 15, 2011 - The normalization of deviance: what are the perioperative
risks?
June 15, 2011
McNamara SA. The normalization of deviance: what are the perioperative risks? AORN J. 2011;93(6):796-
801. doi:10.1016/j.aorn.2011.02.009.
https://psnet.ahrq.gov/issue/normalization-deviance-what-are-perioperative-risks
This commentary…
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psnet.ahrq.gov/node/40626/psn-pdf
July 02, 2014 - Time to sign off on signout.
July 2, 2014
Stein DM, Stetson PD. Commentary: time to sign off on signout. Acad Med. 2011;86(7):804-6.
doi:10.1097/ACM.0b013e31821d8409.
https://psnet.ahrq.gov/issue/time-sign-signout
This commentary suggests standardized sign-outs can improve communication and handoffs.
https://psne…
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psnet.ahrq.gov/node/37354/psn-pdf
November 21, 2007 - Fires during surgeries a bigger risk than thought.
November 21, 2007
Kowalczyk L. Boston Globe. November 7, 2007
https://psnet.ahrq.gov/issue/fires-during-surgeries-bigger-risk-thought
This article reports data suggesting that the number of surgical fires that occur annually may be higher than
health care official…
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psnet.ahrq.gov/node/35487/psn-pdf
September 12, 2016 - Safety improvements urged for MRI facilities.
September 12, 2016
Mitka M. Safety improvements urged for MRI facilities. JAMA. 2005;294(17):2145-8.
https://psnet.ahrq.gov/issue/safety-improvements-urged-mri-facilities
This news story from JAMA summarizes a teleconference on magnetic resonance imaging safety
and sh…
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psnet.ahrq.gov/node/36546/psn-pdf
January 10, 2011 - A systems approach to patient-centered care.
January 10, 2011
Bergeson SC, Dean JD. A systems approach to patient-centered care. JAMA. 2006;296(23):2848-51.
https://psnet.ahrq.gov/issue/systems-approach-patient-centered-care
The authors suggest system-level changes to help health care professionals ensure that they…
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psnet.ahrq.gov/node/36599/psn-pdf
August 09, 2011 - Why Current Breast Pathology Practices Must Be
Evaluated.
August 9, 2011
Dallas, TX: Susan G Komen Breast Cancer Foundation; 2006.
https://psnet.ahrq.gov/issue/why-current-breast-pathology-practices-must-be-evaluated
This report illustrates weaknesses in current pathology practice of breast cancer diagnosis and su…
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psnet.ahrq.gov/node/33611/psn-pdf
July 01, 2005 - In Conversation with…Christopher P. Landrigan, MD
April 1, 2005
In Conversation with…Christopher P. Landrigan, MD. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
Editor's Note: In October 2004, in what immediately became a landmark paper in patient safety, Dr.…
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psnet.ahrq.gov/node/49610/psn-pdf
October 01, 2010 - "Recurrent" Appendicitis
October 1, 2010
Greenberg CC. "Recurrent" Appendicitis. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/recurrent-appendicitis
The Case
An 85-year-old man presented to the emergency department (ED) with right lower quadrant pain. On
physical examination, the patient showed rebound t…