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2761. Bearing witness to the ethics of practice: storying physicians' medical mistake narratives. | PSNet
      psnet.ahrq.gov/issue/bearing-witness-ethics-practice-storying-physicians-medical-mistake-narratives
      July 17, 2024 - Study Bearing witness to the ethics of practice: storying physicians' medical mistake narratives. Citation Text: Carmack HJ. Bearing witness to the ethics of practice: storying physicians' medical mistake narratives. Health Commun. 2010;25(5):449-58. doi:10.1080/10410236.2010.484876. …

2762. System weaknesses as contributing causes of accidents in health care. | PSNet
      psnet.ahrq.gov/issue/system-weaknesses-contributing-causes-accidents-health-care
      August 31, 2022 - Study System weaknesses as contributing causes of accidents in health care. Citation Text: Ternov S, Akselsson R. System weaknesses as contributing causes of accidents in health care. Int J Qual Health Care. 2005;17(1):5-13. Copy Citation Format: Google Scholar PubMed Bib…

2763. Impact of the Care Quality Commission on Provider Performance: Room for Improvement? | PSNet
      psnet.ahrq.gov/issue/impact-care-quality-commission-provider-performance-room-improvement
      November 18, 2015 - Book/Report Impact of the Care Quality Commission on Provider Performance: Room for Improvement? Citation Text: Impact of the Care Quality Commission on Provider Performance: Room for Improvement? Smithson R, Richardson E, Roberts J, et al. The King's Fund, Alliance Manchester Business S…

2764. Description of inpatient medication management using cognitive work analysis. | PSNet
      psnet.ahrq.gov/issue/description-inpatient-medication-management-using-cognitive-work-analysis
      October 19, 2022 - Study Description of inpatient medication management using cognitive work analysis. Citation Text: Pingenot AA, Shanteau J, Sengstacke LTCDN. Description of inpatient medication management using cognitive work analysis. Comput Inform Nurs. 2009;27(6):379-92. doi:10.1097/NCN.0b013e3181b…

2765. Nurses' perception of shift handovers in Europe - results from the European Nurses' Early Exit Study. | PSNet
      psnet.ahrq.gov/issue/nurses-perception-shift-handovers-europe-results-european-nurses-early-exit-study
      September 24, 2016 - Study Nurses' perception of shift handovers in Europe - results from the European Nurses' Early Exit Study. Citation Text: Meissner A, Hasselhorn H-M, Estryn-Behar M, et al. Nurses' perception of shift handovers in Europe: results from the European Nurses' Early Exit Study. J Adv Nurs.…

2766. Exploring the causes of adverse events in hospitals and potential prevention strategies. | PSNet
      psnet.ahrq.gov/issue/exploring-causes-adverse-events-hospitals-and-potential-prevention-strategies
      February 20, 2013 - Study Exploring the causes of adverse events in hospitals and potential prevention strategies. Citation Text: Smits M, Zegers M, Groenewegen PP, et al. Exploring the causes of adverse events in hospitals and potential prevention strategies. BMJ Qual Saf. 2010;19(5). doi:10.1136/qshc.20…

2767. Decision-making processes used by nurses during intravenous drug preparation and administration. | PSNet
      psnet.ahrq.gov/issue/decision-making-processes-used-nurses-during-intravenous-drug-preparation-and-administration
      June 29, 2022 - Study Decision-making processes used by nurses during intravenous drug preparation and administration. Citation Text: Dougherty L, Sque M, Crouch R. Decision-making processes used by nurses during intravenous drug preparation and administration. J Adv Nurs. 2012;68(6):1302-11. doi:10.1…

2768. Job Aid: Model for Improvement and PDSA Cycles (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-model-pdsa.pdf
      June 02, 2025 - Job Aid: Model for Improvement and PDSA Cycles Primary Care Practice Facilitator Training Series 1 Job Aid: Model for Improvement and PDSA Cycles Using the Model for Improvement The Model for Improvement (MFI) is a simple framework that many primary care practices use to help them organize their i…

2769. Filling the gaps on the Institute for Safe Medication Practices (ISMP) Do Not Crush List for Immediate-release Products | PSNet
      psnet.ahrq.gov/issue/filling-gaps-institute-safe-medication-practices-ismp-do-not-crush-list-immediate-release
      July 21, 2021 - Study Filling the gaps on the Institute for Safe Medication Practices (ISMP) Do Not Crush List for Immediate-release Products Citation Text: Filling the gaps on the Institute for Safe Medication Practices (ISMP) Do Not Crush List for Immediate-release Products Uttaro E, Zhao F, Schweigha…

2770. Complexity and safety. | PSNet
      psnet.ahrq.gov/issue/complexity-and-safety
      February 01, 2012 - Commentary Complexity and safety. Citation Text: Carrillo RA. Complexity and safety. J Safety Res. 2011;42(4):293-300. doi:10.1016/j.jsr.2011.06.003. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

2771. Epidemiology of medication-related adverse events in nursing homes. | PSNet
      psnet.ahrq.gov/issue/epidemiology-medication-related-adverse-events-nursing-homes
      March 28, 2012 - Review Epidemiology of medication-related adverse events in nursing homes. Citation Text: Handler S, Wright RM, Ruby CM, et al. Epidemiology of medication-related adverse events in nursing homes. Am J Geriatr Pharmacother. 2006;4(3):264-72. Copy Citation Format: Google Sc…

2772. Introduction | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-1.html
      June 01, 2020 - Operational Measurement of Diagnostic Safety: State of the Science Introduction Previous Page Next Page Table of Contents Operational Measurement of Diagnostic Safety: State of the Science Introduction Special Considerations for Measurement of Diagnostic Safety Getting Ready for Measurement: O…

2773. Fatal errors in nitrous oxide delivery. | PSNet
      psnet.ahrq.gov/issue/fatal-errors-nitrous-oxide-delivery
      March 02, 2011 - Review Fatal errors in nitrous oxide delivery. Citation Text: Herff H, Paal P, Von Goedecke A, et al. Fatal errors in nitrous oxide delivery. Anaesthesia. 2007;62(12):1202-1206. doi:10.1111/j.1365-2044.2007.05193.x. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3…

2774. From good intentions to successful implementation: the case of patient safety in Canada. | PSNet
      psnet.ahrq.gov/issue/good-intentions-successful-implementation-case-patient-safety-canada
      February 24, 2011 - Commentary From good intentions to successful implementation: the case of patient safety in Canada. Citation Text: Thomas PG. From good intentions to successful implementation: the case of patient safety in Canada. Canadian Public Administration/Administration publique du Canada. 2008;…

2775. 131-What-Are-The-4-Es-One-Pager (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/131-what-are-the-4-es-one-pager.docx
      May 24, 2024 - The aim is to Engage hearts and minds and thus, change attitudes and behaviors.1-6 Raise awareness of the problem, communicate benefits of the solution, and lay out the goals for the intervention. · Use unit data, published literature, and national benchmarks. Storytelling is an underrated tool. Engagement is not a on…

2776. Improving self-reporting of adverse drug events in a West Virginia hospital. | PSNet
      psnet.ahrq.gov/issue/improving-self-reporting-adverse-drug-events-west-virginia-hospital
      March 10, 2011 - Study Improving self-reporting of adverse drug events in a West Virginia hospital. Citation Text: Schade CP, Hannah K, Ruddick P, et al. Improving self-reporting of adverse drug events in a West Virginia hospital. Am J Med Qual. 2006;21(5):335-41. Copy Citation Format: Go…

2777. Origin | Agency for Healthcare Research and Quality
      www.ahrq.gov/evidencenow/projects/heart-health/about/origin.html
      March 01, 2021 - Origin Origins of EvidenceNOW The ability to integrate and implement new discoveries into patient care creates a stronger, more effective health care system. But not all discoveries are equal. We turn to evidence to understand what works and how best to integrate effective approaches and treatments into pat…

2778. How surgeons disclose medical errors to patients: a study using standardized patients.   | PSNet
      psnet.ahrq.gov/issue/how-surgeons-disclose-medical-errors-patients-study-using-standardized-patients
      July 10, 2008 - Study How surgeons disclose medical errors to patients: a study using standardized patients.   Citation Text: Chan DK, Gallagher TH, Reznick R, et al. How surgeons disclose medical errors to patients: a study using standardized patients. Surgery. 2005;138(5):851-8. Copy Citation …

2779. Nurse/physician communication through a sensemaking lens: shifting the paradigm to improve patient safety. | PSNet
      psnet.ahrq.gov/issue/nursephysician-communication-through-sensemaking-lens-shifting-paradigm-improve-patient
      June 05, 2024 - Review Nurse/physician communication through a sensemaking lens: shifting the paradigm to improve patient safety. Citation Text: Manojlovich M. Nurse/physician communication through a sensemaking lens: shifting the paradigm to improve patient safety. Med Care. 2010;48(11):941-6. doi:10…

2780. Safeguarding in medication administration: understanding pre-registration nursing students' survey response to patient safety and peer reporting issues. | PSNet
      psnet.ahrq.gov/issue/safeguarding-medication-administration-understanding-pre-registration-nursing-students-survey
      June 27, 2012 - Study Safeguarding in medication administration: understanding pre-registration nursing students' survey response to patient safety and peer reporting issues. Citation Text: Andrew S, Mansour M. Safeguarding in medication administration: understanding pre-registration nursing students' s…