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psnet.ahrq.gov/issue/tragic-error-neuromuscular-blocker-should-prompt-risk-assessment-all-hospitals
November 16, 2015 - This newsletter article discusses an adverse drug event involving a patient who died after receiving … April 29, 2015
A crack in our best armor: "wrong patient" injections from insulin pens … February 19, 2014
Administering just the diluent or one of two vaccine components leaves patients … Misconnection Leading to Arterial Thrombosis
June 28, 2023
Survey … Looking for Meds in All the Wrong Places
October 1, 2012
Weighing in on
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psnet.ahrq.gov/issue/animated-stories-medical-error-means-teaching-undergraduates-patient-safety-evaluation-study
June 10, 2020 - medication safety: a survey study. … June 21, 2023
Virtual patients designed for training against medical error: exploring … the impact of decision-making on learner motivation. … of the mechanisms that impact on student learning in a single cohort over a 5 year curriculum. … students' abilities to probe for contextual issues in simulated patients.
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psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - The delay in appropriate treatment of sepsis
with continued antibiotic therapy on admission resulted … Several studies have been published on these electronic "sniffers" demonstrating limited results.(8,9 … Quality in 2009 of hospital staff from more than 500
hospitals in the United States, more than 80% of respondents … Multistate point-prevalence survey of health
care–associated infections. … Septic shock: an analysis of outcomes for patients with onset on
hospital wards versus intensive care
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psnet.ahrq.gov/issue/piece-my-mind-im-sorry
November 22, 2017 - Being accountable for errors and working to learn from them is key to improving patient safety. … View More
Related Resources
Addressing medicine's bias against patients … December 12, 2018
Patients' concerns about medical errors during hospitalization. … June 11, 2014
Role-modeling and medical error disclosure: a national survey of trainees … January 9, 2014
On higher ground: ethical reasoning and its relationship with error disclosure
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psnet.ahrq.gov/issue/improving-teamwork-general-medical-units-when-teams-do-not-work-face-face
June 12, 2013 - Jt Comm J Qual Patient Saf. 2012;38(10):471-478. … Jt Comm J Qual Patient Saf . 2012; 38 (10) :471-478 . … Jt Comm J Qual Patient Saf. 2012;38(10):471-478. … March 21, 2017
The influence of organizational factors on patient safety: examining successful … : A survey of practices and recommendations.
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psnet.ahrq.gov/issue/classifying-adverse-events-dental-office
July 09, 2014 - Citation
Related Resources From the Same Author(s)
Open wide: looking into the safety … culture of dental school clinics. … November 1, 2023
Are dental patients concerned about safety? … preventable problems in primary care from the patient's perspective with clinician review: a population-level survey … November 4, 2015
The clinical safety of disabled patients: proposal for a methodology
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psnet.ahrq.gov/issue/why-there-another-persons-name-my-infusion-bag-patient-safety-chemotherapy-care-review
May 01, 2024 - 'Why is there another person's name on my infusion bag?' … This thematic review focused on methods to improve safety for chemotherapy patients and found evidence … engagement or teamwork training for patients and families. … 2017
Medication double-checking procedures in clinical practice: a cross-sectional survey … May 4, 2015
The Helsinki Declaration on Patient Safety in Anaesthesiology: the past,
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psnet.ahrq.gov/issue/improving-organizational-climate-quality-and-quality-care-does-membership-collaborative-help
December 14, 2016 - December 14, 2016
Measuring teamwork in health care settings: a review of survey instruments … March 20, 2019
Taking patients' narratives about clinicians from anecdote to science. … July 19, 2023
Optimizing Pediatric Patient Safety in the Emergency Care Setting. … October 19, 2022
The relationship between patients' perception of care and measures of … September 20, 2011
A hospitalization from hell: a patient's perspective on quality.
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psnet.ahrq.gov/issue/life-after-death-aftermath-perioperative-catastrophes
March 29, 2012 - This review addresses how patient death in the operating room affects anesthesiologists and examines … anesthesiologists: results of a national survey. … August 10, 2022
Recognition of adverse drug events in older hospitalized medical patients … patient safety. … of the Committee on Technology.
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psnet.ahrq.gov/issue/use-anatomical-side-markers-general-radiology-systematic-review-current-literature
October 21, 2020 - J Patient Saf. 2022;18(1):e115-e123. doi:10.1097/pts.0000000000000716. … March 18, 2020
Development and validation of a brief culture-of-safety survey. … 2023
For children admitted to hospital, what interventions improve medication safety on … March 1, 2023
Mandating limits on workload, duty, and speed in radiology. … Association of low-dose whole-body computed tomography with missed injury diagnoses and radiation exposure in patients
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psnet.ahrq.gov/node/33861/psn-pdf
July 01, 2018 - On the other hand, take the case of Linda McDougal, whose breast biopsy was switched between two
patients … Increasingly with OpenNotes, patients are reading my
notes (all of my patient now are able to). … Perhaps the
patient should have called me, as I encourage them to do if I don't get back to them on … Based on new screening recommendations for high-risk patients, we're ordering many
imaging tests to … The Betsy Lehman Center and NSPF/IHI have
recently done surveys of patients showing diagnostic errors
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psnet.ahrq.gov/issue/2016-updated-american-society-clinical-oncologyoncology-nursing-society-chemotherapy
February 15, 2023 - guidance to help ensure reliable use of these high-alert medications for both adult and pediatric patients … October 3, 2018
View More
Related Resources
AORN Position Statement on … Patient Safety. … nurses' beliefs and attitudes towards the double-check of chemotherapy medications: a cross-sectional survey … September 24, 2010
Oncology nurses' perceptions about involving patients in the prevention
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psnet.ahrq.gov/issue/trainees-perceptions-patient-safety-practices-recounting-failures-supervision
September 20, 2011 - Trainees' perceptions of patient safety practices: recounting failures of supervision. … Jt Comm J Qual Patient Saf. 2011;37(2):88-95. … Jt Comm J Qual Patient Saf . 2011; 37 (2) :88-95 . … Jt Comm J Qual Patient Saf. 2011;37(2):88-95. … September 20, 2011
Evaluation of clinical practice guidelines on fall prevention and
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psnet.ahrq.gov/issue/computer-alert-system-prevent-injury-adverse-drug-events-development-and-evaluation-community
November 01, 2016 - The effect of structured medication review followed by face-to-face feedback to prescribers on … June 15, 2016
Development and validation of a brief culture-of-safety survey. … November 21, 2021
Can we make postoperative patient handovers safer? … August 8, 2018
Trigger alerts associated with laboratory abnormalities on identifying … Appropriateness of commercially available and partially customized medication dosing alerts among pediatric patients
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psnet.ahrq.gov/issue/failing-wisely-can-promote-safer-healthcare-system
April 30, 2014 - This article advocates for the design and adoption of new approaches to enhance patient safety that … build on what was learned during the COVID-19 pandemic that improved performance to provide care during … Related Resources From the Same Author(s)
The effect of multidisciplinary care teams on … April 24, 2018
Artificial intelligence can be regulated using current patient safety … psychological safety in healthcare teams to inform the development of interventions: combining observational, survey
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psnet.ahrq.gov/issue/high-cost-low-frequency-events-anatomy-and-economics-surgical-mishaps
October 19, 2022 - This prospective, 1-year survey identified adverse outcomes due to errors from surgical intervention … January 6, 2018
The 5th National Audit Project (NAP5) on accidental awareness during … of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients … April 8, 2020
Clinical impact of intraoperative electronic health record downtime on … surgical patients.
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psnet.ahrq.gov/issue/high-reliability-excellent-care-every-time
July 19, 2018 - Related Resources From the Same Author(s)
National quality program achieves improvements in safety … culture and reduction in preventable harms in community hospitals. … June 19, 2019
Managing hospitalized patients with ambulatory pumps: findings from an … ISMP survey—Part 1. … September 13, 2017
Patient and family advisory councils.
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psnet.ahrq.gov/issue/costly-issues-uncommunicative-or
July 29, 2020 - July 29, 2020
Development of a high-value care culture survey: a modified Delphi process … September 29, 2017
Evaluation of clinical practice guidelines on fall prevention and … January 12, 2022
Estimating the impact on patient safety of enabling the digital transfer … of patients' prescription information in the English NHS. … September 9, 2020
An e-Delphi study to obtain expert consensus on the level of risk associated
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psnet.ahrq.gov/issue/how-surgical-trainees-handle-catastrophic-errors-qualitative-study
March 19, 2019 - Citation
Related Resources From the Same Author(s)
Effect of genetic diagnosis on … patients with previously undiagnosed disease. … April 10, 2024
Evaluation of clinical practice guidelines on fall prevention and management … A survey of North American surgical residents and fellows. … January 28, 2015
Use of the Safety Attitudes Questionnaire as a measure in patient safety
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psnet.ahrq.gov/issue/surgeon-age-and-operative-mortality-united-states
August 02, 2015 - and operative risk and conclude that, in general, surgeon age was not an important risk factor for patient … Related Resources From the Same Author(s)
Composite measures for profiling hospitals on … Assessment of Healthcare Providers and Systems survey. … April 18, 2019
Safety culture and complications after bariatric surgery. … October 6, 2011
Time of day effects on the incidence of anesthetic adverse events.