AHRQ Search | Home Page

Prevent errors during emergency use of hypertonic sodium chloride solutions. | PSNet

psnet.ahrq.gov/issue/prevent-errors-during-emergency-use-hypertonic-sodium-chloride-solutions

March 10, 2021 - Newspaper/Magazine Article Prevent errors during emergency use of hypertonic sodium chloride solutions. Citation Text: Prevent errors during emergency use of hypertonic sodium chloride solutions. ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4. Copy Citat…

Missed nursing care: a concept analysis. | PSNet

psnet.ahrq.gov/issue/missed-nursing-care-concept-analysis

January 19, 2022 - Commentary Missed nursing care: a concept analysis. Citation Text: Kalisch BJ, Landstrom GL, Hinshaw AS. Missed nursing care: a concept analysis. J Adv Nurs. 2009;65(7):1509-17. doi:10.1111/j.1365-2648.2009.05027.x. Copy Citation Format: DOI Google Scholar PubMed BibTeX End…

Improving patient safety in radiotherapy by learning from near misses, incidents and errors. | PSNet

psnet.ahrq.gov/issue/improving-patient-safety-radiotherapy-learning-near-misses-incidents-and-errors

July 10, 2017 - Commentary Improving patient safety in radiotherapy by learning from near misses, incidents and errors. Citation Text: Williams M. Improving patient safety in radiotherapy by learning from near misses, incidents and errors. Br J Radiol. 2007;80(953):297-301. Copy Citation Format:…

Promoting patient safety through prospective risk identification: example from peri-operative care. | PSNet

psnet.ahrq.gov/issue/promoting-patient-safety-through-prospective-risk-identification-example-peri-operative-care

September 23, 2020 - Study Promoting patient safety through prospective risk identification: example from peri-operative care. Citation Text: Smith AF, Boult M, Woods I, et al. Promoting patient safety through prospective risk identification: example from peri-operative care. Qual Saf Health Care. 2010;19(…

Seeking systems-based facilitators of safety and healthcare resilience: a thematic review of incident reports. | PSNet

psnet.ahrq.gov/issue/seeking-systems-based-facilitators-safety-and-healthcare-resilience-thematic-review-incident

December 06, 2023 - Study Seeking systems-based facilitators of safety and healthcare resilience: a thematic review of incident reports. Citation Text: Leon C, Hogan H, Jani YH. Seeking systems-based facilitators of safety and healthcare resilience: a thematic review of incident reports. Int J Qual Health C…

Computer-assisted bar-coding system significantly reduces clinical laboratory specimen identification errors in a pediatric oncology hospital. | PSNet

psnet.ahrq.gov/issue/computer-assisted-bar-coding-system-significantly-reduces-clinical-laboratory-specimen

July 29, 2020 - Study Computer-assisted bar-coding system significantly reduces clinical laboratory specimen identification errors in a pediatric oncology hospital. Citation Text: Hayden RT, Patterson DJ, Jay DW, et al. Computer-assisted bar-coding system significantly reduces clinical laboratory spec…

Diagnostic Excellence in U.S. Rural Healthcare: A Call to Action. | PSNet

psnet.ahrq.gov/issue/diagnostic-excellence-us-rural-healthcare-call-action

December 22, 2018 - Book/Report Diagnostic Excellence in U.S. Rural Healthcare: A Call to Action. Citation Text: Ali KJ, Galvez NJ, Craig S, et al. Diagnostic Excellence In U.s. Rural Healthcare: A Call To Action. Rockville, MD: Agency for Healthcare Research and Quality; September 2024. AHRQ Publication No…

Evaluation of a predevelopment service delivery intervention: an application to improve clinical handovers. | PSNet

psnet.ahrq.gov/issue/evaluation-predevelopment-service-delivery-intervention-application-improve-clinical

March 06, 2013 - Study Evaluation of a predevelopment service delivery intervention: an application to improve clinical handovers. Citation Text: Yao GL, Novielli N, Manaseki-Holland S, et al. Evaluation of a predevelopment service delivery intervention: an application to improve clinical handovers. BMJ …

The future of graduate medical education: a systems-based approach to ensure patient safety. | PSNet

psnet.ahrq.gov/issue/future-graduate-medical-education-systems-based-approach-ensure-patient-safety

October 18, 2017 - Commentary The future of graduate medical education: a systems-based approach to ensure patient safety. Citation Text: Bagian JP. The Future of Graduate Medical Education: A Systems-Based Approach to Ensure Patient Safety. Acad Med. 2015;90(9):1199-202. doi:10.1097/ACM.0000000000000824. …

Collaboration between pharmacists, physicians and nurse practitioners: a qualitative investigation of working relationships in the inpatient medical setting. | PSNet

psnet.ahrq.gov/issue/collaboration-between-pharmacists-physicians-and-nurse-practitioners-qualitative

November 16, 2022 - Study Collaboration between pharmacists, physicians and nurse practitioners: a qualitative investigation of working relationships in the inpatient medical setting. Citation Text: Makowsky MJ, Schindel TJ, Rosenthal M, et al. Collaboration between pharmacists, physicians and nurse pract…

Survey suggests disrespectful behaviors persist in healthcare: practitioners speak up (yet again) – Parts I and II. | PSNet

psnet.ahrq.gov/issue/survey-suggests-disrespectful-behaviors-persist-healthcare-practitioners-speak-yet-again

February 23, 2022 - Newspaper/Magazine Article Survey suggests disrespectful behaviors persist in healthcare: practitioners speak up (yet again) – Parts I and II. Citation Text: Survey suggests disrespectful behaviors persist in healthcare: practitioners speak up (yet again) – Parts I and II. ISMP Medicatio…

Root Cause Analysis Gone Wrong | PSNet

psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong

August 28, 2024 - Root Cause Analysis Gone Wrong Citation Text: Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…

Medical error in the care of the unrepresented: disclosure and apology for a vulnerable patient population. | PSNet

psnet.ahrq.gov/issue/medical-error-care-unrepresented-disclosure-and-apology-vulnerable-patient-population

March 13, 2024 - Commentary Medical error in the care of the unrepresented: disclosure and apology for a vulnerable patient population. Citation Text: Byju AS, Mayo K. Medical error in the care of the unrepresented: disclosure and apology for a vulnerable patient population. J Med Ethics. 2019;45(12):821…

Learning mechanisms to limit medication administration errors. | PSNet

psnet.ahrq.gov/issue/learning-mechanisms-limit-medication-administration-errors

August 30, 2017 - Study Learning mechanisms to limit medication administration errors. Citation Text: Drach-Zahavy A, Pud D. Learning mechanisms to limit medication administration errors. J Adv Nurs. 2010;66(4). doi:10.1111/j.1365-2648.2010.05294.x. Copy Citation Format: DOI Google Scholar …

Resident Duty Hours Across Borders: An International Perspective. | PSNet

psnet.ahrq.gov/issue/resident-duty-hours-across-borders-international-perspective

February 27, 2019 - Special or Theme Issue Resident Duty Hours Across Borders: An International Perspective. Citation Text: Resident Duty Hours Across Borders: An International Perspective. Imrie KR, Frank JR, Parshuram CS, eds. BMC Med Educ. 2014;14(suppl1):S1-S18. Copy Citation Save …

Inadvertent Castration | PSNet

psnet.ahrq.gov/web-mm/inadvertent-castration

October 27, 2010 - Inadvertent Castration Citation Text: Calland FJ. Inadvertent Castration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubM…

Fatal Solutions: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture. | PSNet

psnet.ahrq.gov/issue/fatal-solutions-how-healthcare-system-used-tragedy-transform-itself-and-redefine-just-culture

May 16, 2019 - Book/Report Fatal Solutions: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture. Citation Text: Fatal Solutions: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture. Davies JM, Steinke C, Flemons WW. New York, NY: Productivit…

Cultural diversity: what role does it play in patient safety? | PSNet

psnet.ahrq.gov/issue/cultural-diversity-what-role-does-it-play-patient-safety

June 15, 2011 - Commentary Cultural diversity: what role does it play in patient safety? Citation Text: Ardoin KB, Wilson KB. Cultural diversity: what role does it play in patient safety? Nurs Womens Health. 2010;14(4):322-6. doi:10.1111/j.1751-486X.2010.01563.x. Copy Citation Format: DO…

Clinical problem-solving. Lost in transcription. | PSNet

psnet.ahrq.gov/issue/clinical-problem-solving-lost-transcription

September 20, 2011 - Commentary Clinical problem-solving. Lost in transcription. Citation Text: Kalus RM, Shojania KG, Amory JK, et al. Clinical problem-solving. Lost in transcription. N Engl J Med. 2006;355(14):1487-91. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNot…

Interruptions and blood transfusion checks: lessons from the simulated operating room. | PSNet

psnet.ahrq.gov/issue/interruptions-and-blood-transfusion-checks-lessons-simulated-operating-room

September 24, 2016 - Study Interruptions and blood transfusion checks: lessons from the simulated operating room. Citation Text: Liu D, Grundgeiger T, Sanderson P, et al. Interruptions and blood transfusion checks: lessons from the simulated operating room. Anesth Analg. 2009;108(1):219-22. doi:10.1213/ane.0…

Search AHRQ

Results