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2221. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36544/psn-pdf
      July 14, 2010 - Targeted chart review of pediatric patient safety events identified by the Agency for Healthcare Research and Quality's Patient Safety Indicators methodology. July 14, 2010 Scanlon M, Miller MR, Harris JM, et al. Targeted Chart Review of Pediatric Patient Safety Events Identified by the Agency for Healthcare Resea…

2222. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39101/psn-pdf
      March 05, 2010 - Interventions to improve team effectiveness: a systematic review. March 5, 2010 Buljac-Samardzic M, van Doorn CMD-, van Wijngaarden JDH, et al. Interventions to improve team effectiveness: a systematic review. Health Policy (New York). 2010;94(3):183-95. doi:10.1016/j.healthpol.2009.09.015. https://psnet.ahrq.gov…

2223. Medical errors: mandatory reporting, voluntary reporting, or both? | PSNet
      psnet.ahrq.gov/issue/medical-errors-mandatory-reporting-voluntary-reporting-or-both
      February 28, 2024 - Commentary Medical errors: mandatory reporting, voluntary reporting, or both? Citation Text: Grepperud S. Medical Errors: Mandatory Reporting, Voluntary Reporting, or Both? European Journal of Law and Economics. 2005;20(1). doi:10.1007/s10657-005-1019-8. Copy Citation Format: …

2224. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45190/psn-pdf
      February 15, 2017 - Biases in detection of apparent "weekend effect" on outcome with administrative coding data: population based study of stroke. February 15, 2017 Li L, Rothwell PM, Study OV. Biases in detection of apparent "weekend effect" on outcome with administrative coding data: population based study of stroke. BMJ. 2016;353:…

2225. Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. | PSNet
      psnet.ahrq.gov/issue/discontinuity-and-disaster-gaps-and-negotiation-culpability-medication-delivery
      June 24, 2020 - Commentary Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. Citation Text: Dekker SWA. Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. J Law Med Ethics. 2007;35(3):463-70. Copy Citation Format:…

2226. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40725/psn-pdf
      October 16, 2012 - Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. October 16, 2012 Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA. 2011;306(8):840-7. doi:10.10…

2227. Strategies for learning from failure. | PSNet
      psnet.ahrq.gov/issue/strategies-learning-failure
      September 25, 2024 - Commentary Classic Strategies for learning from failure. Citation Text: Edmondson A. Strategies of learning from failure. Harv Bus Rev. 2011;89(4):48-55, 137. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnot…

2228. Patient Safety. | PSNet
      psnet.ahrq.gov/issue/patient-safety-7
      November 16, 2015 - Book/Report Patient Safety. Citation Text: Patient Safety. Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I. Copy Citation Save Save to your library Print …

2229. Multifactorial Medication Mishap | PSNet
      psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
      September 01, 2016 - Table 1 ).( 4 ) Although other categorizations also exist, this commentary will use ISMP's model to analyze … Readers who also wish to analyze errors in this manner can use a worksheet available on ISMP's Web site

2230. Nurses' role in patient safety. | PSNet
      psnet.ahrq.gov/issue/nurses-role-patient-safety
      June 09, 2011 - Commentary Nurses' role in patient safety. Citation Text: Hughes RG, Clancy CM. Nurses' role in patient safety. J Nurs Care Qual. 2009;24(1):1-4. doi:10.1097/NCQ.0b013e31818f55c7. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …

2231. Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care. | PSNet
      psnet.ahrq.gov/issue/systematic-review-incidence-and-characteristics-preventable-adverse-drug-events-ambulatory
      July 15, 2010 - Review Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care. Citation Text: Thomsen LA, Winterstein AG, S⊘ndergaard B, et al. Systematic Review of the Incidence and Characteristics of Preventable Adverse Drug Events in Ambulatory …

2232. Nursing student errors and near misses: three years of data. | PSNet
      psnet.ahrq.gov/issue/nursing-student-errors-and-near-misses-three-years-data
      October 20, 2021 - Study Nursing student errors and near misses: three years of data. Citation Text: Silvestre JH, Spector ND. Nursing student errors and near misses: three years of data. J Nurs Educ. 2023;62(1):12-19. doi:10.3928/01484834-20221109-05. Copy Citation Format: DOI Google Scholar…

2233. Ambulance stretcher adverse events. | PSNet
      psnet.ahrq.gov/issue/ambulance-stretcher-adverse-events
      March 23, 2011 - Study Ambulance stretcher adverse events. Citation Text: Wang HE, Weaver MD, Abo BN, et al. Ambulance stretcher adverse events. Qual Saf Health Care. 2009;18(3):213-216. doi:10.1136/qshc.2007.024562. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML En…

2234. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. | PSNet
      psnet.ahrq.gov/issue/using-six-sigma-reduce-medication-errors-home-delivery-pharmacy-service
      November 18, 2015 - Study Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Citation Text: Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24. Copy Citation …

2235. Complication rates on weekends and weekdays in US hospitals. | PSNet
      psnet.ahrq.gov/issue/complication-rates-weekends-and-weekdays-us-hospitals
      August 31, 2011 - Study Complication rates on weekends and weekdays in US hospitals. Citation Text: Bendavid E, Kaganova Y, Needleman J, et al. Complication rates on weekends and weekdays in US hospitals. Am J Med. 2007;120(5):422-8. Copy Citation Format: Google Scholar PubMed BibTeX EndNo…

2236. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.72_slideshow.ppt
      September 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case September 2004 Poor Prognosis? Source and Credits This presentation is based on the September 2004 AHRQ WebM&M Spotlight Case in Surgery See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Elizabeth B. Lamont, M…

2237. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38956/psn-pdf
      March 18, 2015 - Safety in Doses. March 18, 2015 London, UK: National Patient Safety Agency; 2009. ISBN: 9781906624088. https://psnet.ahrq.gov/issue/safety-doses This publication analyzes 72,482 medication incidents reported to the National Health Service and highlights areas for improvement and prevention. https://psnet.ahrq.gov…

2238. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41998/psn-pdf
      January 30, 2013 - Involving Patients in Improving Safety. January 30, 2013 London, UK: The Health Foundation; January 2013. https://psnet.ahrq.gov/issue/involving-patients-improving-safety This review analyzes research on engaging patients in safety improvement and details which strategies are most effective. https://psnet.ahrq.go…

2239. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39591/psn-pdf
      March 21, 2016 - Annual Benchmarking Report: Malpractice Risks in Surgery. March 21, 2016 Cambridge, MA: CRICO/RMF Strategies; 2010. https://psnet.ahrq.gov/issue/annual-benchmarking-report-malpractice-risks-surgery Analyzing data from 3300 surgical malpractice cases, this report describes errors across the continuum of surgical c…

2240. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37765/psn-pdf
      May 24, 2015 - The Rebecca O'Malley Report. May 24, 2015 Cork, Ireland: Health Information and Quality Authority; March 21, 2008. https://psnet.ahrq.gov/issue/rebecca-omalley-report This report analyzes the findings of a diagnostic error investigation and provides numerous recommendations to improve standards for treating sympto…