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  1. Returning to the roots of culture: a review and re-conceptualisation of safety culture. | PSNet

    psnet.ahrq.gov/issue/returning-roots-culture-review-and-re-conceptualisation-safety-culture
    December 16, 2020 - Review Returning to the roots of culture: a review and re-conceptualisation of safety culture. Citation Text: Edwards JRD, Davey J, Armstrong K. Returning to the roots of culture: A review and re-conceptualisation of safety culture. Saf Sci. 2013;55. doi:10.1016/j.ssci.2013.01.004. Co…

  2. Patient safety answers require outreach, in-reach, and partnerships. | PSNet

    psnet.ahrq.gov/issue/patient-safety-answers-require-outreach-reach-and-partnerships
    August 23, 2023 - Commentary Patient safety answers require outreach, in-reach, and partnerships. Citation Text: Burt HA. Patient Safety Answers Require Outreach, In-reach, and Partnerships. J Hosp Librariansh. 2011;11(4). doi:10.1080/15323269.2011.611436. Copy Citation Format: DOI Google …

  3. Impact of a standard medication chart on prescribing errors: a before-and-after audit. | PSNet

    psnet.ahrq.gov/issue/impact-standard-medication-chart-prescribing-errors-and-after-audit
    May 02, 2012 - Study Impact of a standard medication chart on prescribing errors: a before-and-after audit. Citation Text: Coombes ID, Stowasser DA, Reid C, et al. Impact of a standard medication chart on prescribing errors: a before-and-after audit. Qual Saf Health Care. 2009;18(6):478-85. doi:10.11…

  4. Ambiguous abbreviations: an audit of abbreviations in paediatric note keeping. | PSNet

    psnet.ahrq.gov/issue/ambiguous-abbreviations-audit-abbreviations-paediatric-note-keeping
    November 16, 2022 - Study Ambiguous abbreviations: an audit of abbreviations in paediatric note keeping. Citation Text: Sheppard JE, Weidner LCE, Zakai S, et al. Ambiguous abbreviations: an audit of abbreviations in paediatric note keeping. Arch Dis Child. 2008;93(3):204-6. Copy Citation Format: …

  5. Preventing errors when preparing and administering medications via enteral feeding tubes. | PSNet

    psnet.ahrq.gov/issue/preventing-errors-when-preparing-and-administering-medications-enteral-feeding-tubes
    November 30, 2016 - Newspaper/Magazine Article Preventing errors when preparing and administering medications via enteral feeding tubes. Citation Text: Preventing errors when preparing and administering medications via enteral feeding tubes. ISMP Medication Safety Alert! Acute care edition. November 17, 202…

  6. Between a rock and a hard place: disclosing medical errors. | PSNet

    psnet.ahrq.gov/issue/between-rock-and-hard-place-disclosing-medical-errors
    October 19, 2022 - Commentary Between a rock and a hard place: disclosing medical errors. Citation Text: Crone KG, Muraski MB, Skeel JD, et al. Between a rock and a hard place: disclosing medical errors. Clin Chem. 2006;52(9):1809-14. Copy Citation Format: Google Scholar PubMed BibTeX EndNo…

  7. Wide heart monitor use tied to missed alarms. | PSNet

    psnet.ahrq.gov/issue/wide-heart-monitor-use-tied-missed-alarms
    July 19, 2023 - Newspaper/Magazine Article Wide heart monitor use tied to missed alarms. Citation Text: Funk M, Winkler CG, May JL, et al. Unnecessary arrhythmia monitoring and underutilization of ischemia and QT interval monitoring in current clinical practice: baseline results of the Practical Use o…

  8. Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices. | PSNet

    psnet.ahrq.gov/issue/survey-shows-room-improvement-two-new-ismp-targeted-medication-safety-best-practices
    February 12, 2020 - Newspaper/Magazine Article Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices. Citation Text: Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices. ISMP Medication Safety Alert! Acute care edition. July 3…

  9. Fatality involving vinblastine overdose as a result of a complex medical error. | PSNet

    psnet.ahrq.gov/issue/fatality-involving-vinblastine-overdose-result-complex-medical-error
    January 25, 2023 - Study Fatality involving vinblastine overdose as a result of a complex medical error. Citation Text: Kłys M, Konopka T, Scisłowski M, et al. Fatality involving vinblastine overdose as a result of a complex medical error. Cancer Chemother Pharmacol. 2007;59(1):89-95. Copy Citation …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72564/psn-pdf
    November 14, 2018 - Antibiotic and Opioid Stewardship in Dentistry December 7, 2020 Suda KJ, Fitall E, Hall KK, et al. Antibiotic and Opioid Stewardship in Dentistry. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/antibiotic-and-opioid-stewardship-dentistry Introduction Medication stewardship refers to efforts by frontlin…

  11. Perils in Diagnosing a Stroke | PSNet

    psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
    August 15, 2017 - Hospitals Physicians Neurology Clinical Misdiagnosis Medication Errors/Preventable Adverse … Drug Events View More

  12. In Conversation with...Mark Chassin, MD, MPP, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
    April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH April 1, 2009  Also Read an Essay Citation Text: In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009.In Conversation with...Mark Chassin, MD, MPP, MPH . PSNet [internet]. Rockville (MD): A…

  13. Patient Safety in Primary Care | PSNet

    psnet.ahrq.gov/perspective/patient-safety-primary-care
    January 31, 2020 - Annual Perspective Patient Safety in Primary Care February 21, 2020  View more articles from the same authors. Citation Text: Schiff G, Hall KK, Fitall E. Patient Safety in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…

  14. Lost in the Black Hole | PSNet

    psnet.ahrq.gov/web-mm/lost-black-hole
    December 01, 2005 - Lost in the Black Hole Citation Text: Wachter R. Lost in the Black Hole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49417/psn-pdf
    October 01, 2003 - Lost in the Black Hole October 1, 2003 Wachter R. Lost in the Black Hole. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/lost-black-hole The Case A 38-year-old married, monogamous female came to the emergency department with aseptic meningitis. She had a remote history of gonorrhea, no environmental exposu…

  16. Patient Safety in Home Dialysis | PSNet

    psnet.ahrq.gov/perspective/patient-safety-home-dialysis
    April 28, 2021 - View More See More About The Topic Home Care Nephrology Side Effects/Adverse … Drug Reactions Nosocomial Infections Patient Falls View More

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33833/psn-pdf
    May 01, 2017 - In Conversation With… David Juurlink, MD, PhD May 1, 2017 In Conversation With… David Juurlink, MD, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd Editor's note: Dr. Juurlink is professor of medicine, pediatrics, and health policy at the University of Toronto, w…

  18. Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/exploring-roots-unintended-safety-threats-associated-introduction-hospital-eprescribing
    December 21, 2022 - Study Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study. Citation Text: Mozaffar H, Cresswell K, Williams R, et al. Exploring the roots of unintended…

  19. Assessment of health information technology-related outpatient diagnostic delays in the US Veterans Affairs health care system: a qualitative study of aggregated root cause analysis data. | PSNet

    psnet.ahrq.gov/issue/assessment-health-information-technology-related-outpatient-diagnostic-delays-us-veterans
    June 24, 2020 - Study Assessment of health information technology-related outpatient diagnostic delays in the US Veterans Affairs health care system: a qualitative study of aggregated root cause analysis data. Citation Text: Powell L, Sittig DF, Chrouser K, et al. Assessment of health information techno…

  20. Are teaching hospitals treated fairly in the Hospital-Acquired Condition Reduction Program? | PSNet

    psnet.ahrq.gov/issue/are-teaching-hospitals-treated-fairly-hospital-acquired-condition-reduction-program
    July 11, 2018 - Study Are teaching hospitals treated fairly in the Hospital-Acquired Condition Reduction Program? Citation Text: Mohajer MA, Joiner KA, Nix DE. Are Teaching Hospitals Treated Fairly in the Hospital-Acquired Condition Reduction Program? Acad Med. 2018;93(12):1827-1832. doi:10.1097/ACM.000…
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