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psnet.ahrq.gov/issue/medication-administration-time-study-mats-nursing-staff-performance-medication-administration
February 21, 2018 - Study
Medication Administration Time Study (MATS): nursing staff performance of medication administration.
Citation Text:
Elganzouri ES, Standish CA, Androwich I. Medication Administration Time Study (MATS): nursing staff performance of medication administration. J Nurs Admin. 2009;39(5)…
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psnet.ahrq.gov/issue/detection-and-prevention-medication-errors-using-real-time-bedside-nurse-charting
September 27, 2017 - Study
Detection and prevention of medication errors using real-time bedside nurse charting.
Citation Text:
Nelson NC, Evans RS, Samore MH, et al. Detection and Prevention of Medication Errors Using Real-Time Bedside Nurse Charting. Journal of the American Medical Informatics Associatio…
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psnet.ahrq.gov/issue/elusive-balance-residents-work-hours-and-continuity-care
July 19, 2017 - Commentary
An elusive balance — residents' work hours and the continuity of care.
Citation Text:
Okie S. An elusive balance--residents' work hours and the continuity of care. N Engl J Med. 2007;356(26):2665-2667.
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psnet.ahrq.gov/issue/team-checkup-tool-evaluating-qi-team-activities-and-giving-feedback-senior-leaders
November 27, 2012 - Commentary
The Team Checkup Tool: evaluating QI team activities and giving feedback to senior leaders.
Citation Text:
Lubomski LH, Marsteller JA, Hsu Y-J, et al. The team checkup tool: evaluating QI team activities and giving feedback to senior leaders. Jt Comm J Qual Patient Saf. 2008;3…
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psnet.ahrq.gov/issue/medical-error-identification-disclosure-and-reporting-do-emergency-medicine-provider-groups
April 11, 2011 - Study
Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ?
Citation Text:
Hobgood C, Weiner B, Tamayo-Sarver JH. Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ? Acad Emerg Med. 2006…
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psnet.ahrq.gov/issue/incidence-and-impact-physician-and-nurse-disruptive-behaviors-emergency-department
February 03, 2010 - Study
Incidence and impact of physician and nurse disruptive behaviors in the emergency department.
Citation Text:
Rosenstein AH, Naylor B. Incidence and impact of physician and nurse disruptive behaviors in the emergency department. J Emerg Med. 2012;43(1):139-48. doi:10.1016/j.jemerm…
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psnet.ahrq.gov/issue/reasons-accident-causation-model-application-adverse-events-acute-care
October 29, 2014 - Commentary
Reason's accident causation model: application to adverse events in acute care.
Citation Text:
Elliott M, Page K, Worrall-Carter L. Reason's accident causation model: application to adverse events in acute care. Contemp Nurse. 2012;43(1):22-8. doi:10.5172/conu.2012.43.1.22.
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psnet.ahrq.gov/issue/what-patient-safety-culture-review-literature
July 19, 2023 - Review
What is patient safety culture? A review of the literature.
Citation Text:
Sammer CE, Lykens K, Singh KP, et al. What is patient safety culture? A review of the literature. J Nurs Scholarsh. 2010;42(2):156-65. doi:10.1111/j.1547-5069.2009.01330.x.
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psnet.ahrq.gov/issue/diagnostic-error-internal-medicine
May 25, 2022 - Study
Diagnostic error in internal medicine.
Citation Text:
Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.
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psnet.ahrq.gov/issue/medication-errors-involving-intravenous-administration-route-characteristics-voluntarily
January 31, 2018 - Review
Medication errors involving the intravenous administration route: characteristics of voluntarily reported medication errors.
Citation Text:
Wolf ZR. Medication Errors Involving the Intravenous Administration Route: Characteristics of Voluntarily Reported Medication Errors. J Infus…
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psnet.ahrq.gov/issue/ismp-national-vaccine-errors-reporting-program-2017-analysis-part-1-and-part-2
December 27, 2018 - Newspaper/Magazine Article
ISMP National Vaccine Errors Reporting Program 2017 analysis—part 1 and part 2.
Citation Text:
ISMP National Vaccine Errors Reporting Program 2017 analysis—part 1 and part 2. ISMP Medication Safety Alert! Acute Care Edition. June 14, 2018,23:1-5. June 28, 2018;…
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psnet.ahrq.gov/issue/safety-issues-related-electronic-medical-record-emr-synthesis-literature-last-decade-2000
January 20, 2016 - Review
Safety issues related to the electronic medical record (EMR): synthesis of the literature from the last decade, 2000–2009.
Citation Text:
Harrington L, Kennerly DA, Johnson C. Safety issues related to the electronic medical record (EMR): synthesis of the literature from the last…
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psnet.ahrq.gov/issue/use-surgical-safety-checklist-improve-team-communication
August 08, 2018 - Commentary
Use of a surgical safety checklist to improve team communication.
Citation Text:
Cabral RA, Eggenberger T, Keller K, et al. Use of a surgical safety checklist to improve team communication. AORN J. 2016;104(3):206-216. doi:10.1016/j.aorn.2016.06.019.
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psnet.ahrq.gov/issue/pediatric-vaccination-errors-application-5-rights-framework-national-error-reporting-database
September 21, 2008 - Study
Pediatric vaccination errors: application of the "5 rights" framework to a national error reporting database.
Citation Text:
Bundy DG, Shore AD, Morlock L, et al. Pediatric vaccination errors: application of the "5 rights" framework to a national error reporting database. Vaccine.…
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psnet.ahrq.gov/issue/older-adults-are-often-misdiagnosed-specialized-ers-and-trained-clinicians-can-help
July 28, 2021 - Newspaper/Magazine Article
Older adults are often misdiagnosed. Specialized ERs and trained clinicians can help.
Citation Text:
Milne-Tyte A. Older adults are often misdiagnosed. Specialized ERs and trained clinicians can help. Health Shots. National Public Radio. July 30, 2024;
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psnet.ahrq.gov/issue/cascade-iatrogenesis-factors-leading-development-adverse-events-hospitalized-older-adults
June 27, 2012 - Commentary
Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults.
Citation Text:
Thornlow D, Anderson RA, Oddone E. Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults. Int J Nurs Stud…
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psnet.ahrq.gov/issue/survey-use-time-out-protocols-emergency-medicine
November 30, 2012 - Study
A survey of the use of time-out protocols in emergency medicine.
Citation Text:
Kelly JJ, Farley HL, O'Cain C, et al. A survey of the use of time-out protocols in emergency medicine. Jt Comm J Qual Patient Saf. 2011;37(6):285-288.
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psnet.ahrq.gov/issue/using-information-technology-improve-quality-and-safety-emergency-care
July 13, 2010 - Commentary
Using information technology to improve the quality and safety of emergency care.
Citation Text:
Handel DA, Wears RL, Nathanson LA, et al. Using Information Technology to Improve the Quality and Safety of Emergency Care. Academic Emergency Medicine. 2011;18(6). doi:10.1111/j…
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psnet.ahrq.gov/node/43658/psn-pdf
December 19, 2014 - https://psnet.ahrq.gov/primer/handoffs-and-signouts
https://psnet.ahrq.gov/issue/interprofessional-approaches-patient-safety
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psnet.ahrq.gov/node/44702/psn-pdf
December 16, 2015 - that contribute to alarm
fatigue, this review outlines technical, organizational, and educational approaches