-
psnet.ahrq.gov/issue/change-what-can-actually-make-tough-times-better-patient-centred-patient-safety-intervention
September 24, 2017 - Study
"Change is what can actually make the tough times better": a patient-centred patient safety intervention delivered in collaboration with hospital volunteers.
Citation Text:
Louch G, Mohammed MA, Hughes L, et al. "Change is what can actually make the tough times better": A patient-c…
-
psnet.ahrq.gov/issue/detecting-unapproved-abbreviations-electronic-medical-record
August 08, 2018 - Study
Detecting unapproved abbreviations in the electronic medical record.
Citation Text:
Capraro A, Stack AM, Harper MB, et al. Detecting unapproved abbreviations in the electronic medical record. Jt Comm J Qual Patient Saf. 2012;38(4):178-183. doi:10.1016/s1553-7250(12)38023-9.
Copy …
-
psnet.ahrq.gov/issue/interprofessional-handover-and-patient-safety-anaesthesia-observational-study-handovers
April 18, 2011 - Study
Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room.
Citation Text:
Smith AF, Pope C, Goodwin D, et al. Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery r…
-
psnet.ahrq.gov/issue/quality-improvements-decreasing-medication-administration-errors-made-nursing-staff-academic
March 24, 2019 - Study
Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era.
Citation Text:
Wang H-F, Jin J-F,…
-
psnet.ahrq.gov/issue/risk-factors-wrong-site-surgery-study-1166-reports-informed-consent-and-schedule-errors
January 20, 2021 - Study
Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors.
Citation Text:
Taylor MA, Yonash RA. Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors. Patient Safety. 2024;6(1):1-11. doi:10.…
-
psnet.ahrq.gov/issue/clinicians-satisfaction-cpoe-ease-use-and-effect-clinicians-workflow-efficiency-and
August 10, 2022 - Study
Clinicians' satisfaction with CPOE ease of use and effect on clinicians' workflow, efficiency and medication safety.
Citation Text:
Khajouei R, Wierenga PC, Hasman A, et al. Clinicians satisfaction with CPOE ease of use and effect on clinicians' workflow, efficiency and medicatio…
-
psnet.ahrq.gov/innovation/improving-formal-incivility-reporting-ambulatory-oncology-implementing-civic-duty
March 14, 2022 - EMERGING INNOVATIONS
Improving formal incivility reporting in ambulatory oncology: implementing the CIVIC Duty program.
Citation Text:
Gordon JN. Improving formal incivility reporting in ambulatory oncology: implementing the CIVIC Duty program. Clin J Oncol Nurs. 2023;27(6):602-606. doi:10.1188/23…
-
psnet.ahrq.gov/issue/hospitalwide-adverse-drug-events-and-after-limiting-weekly-work-hours-medical-residents-80
May 04, 2010 - Study
Hospitalwide adverse drug events before and after limiting weekly work hours of medical residents to 80.
Citation Text:
Mycyk MB, McDaniel MR, Fotis MA, et al. Hospitalwide adverse drug events before and after limiting weekly work hours of medical residents to 80. Am J Health Sys…
-
psnet.ahrq.gov/issue/identifying-and-characterizing-preventable-adverse-drug-events-prioritizing-pharmacist
July 15, 2010 - Study
Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospitals.
Citation Text:
Jeon N, Staley B, Johns T, et al. Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospital…
-
psnet.ahrq.gov/issue/suboptimal-compliance-surgical-safety-checklists-colorado-prospective-observational-study
May 23, 2018 - Study
Suboptimal compliance with surgical safety checklists in Colorado: a prospective observational study reveals differences between surgical specialties.
Citation Text:
Biffl WL, Gallagher AW, Pieracci FM, et al. Suboptimal compliance with surgical safety checklists in Colorado: A pro…
-
psnet.ahrq.gov/issue/can-preventable-adverse-events-be-predicted-among-hospitalized-older-patients-development-and
March 18, 2013 - Study
Can preventable adverse events be predicted among hospitalized older patients? The development and validation of a predictive model.
Citation Text:
Van De Steeg L, Langelaan M, Wagner C. Can preventable adverse events be predicted among hospitalized older patients? The development …
-
psnet.ahrq.gov/web-mm/lethal-cap
December 19, 2018 - Lethal Cap
Citation Text:
Schillinger D. Lethal Cap. 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 PubMedId RIS
Do…
-
psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
January 01, 2015 - Annual Perspective
Patient Safety and Opioid Medications
Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2016
View more articles from the same authors.
Citation Text:
Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. Ro…
-
psnet.ahrq.gov/node/33834/psn-pdf
May 22, 2017 - Opioid Overdose as a Patient Safety Problem
May 22, 2017
Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
Perspective
Opioids serve a valuable role in the treatment of acute pain and pain associat…
-
psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
View more articles from the same authors.
Citation Text:
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
June 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case June 2005
Getting to the Root of the Matter
Source and Credits
This presentation is based on the June 2005
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Scott Flanders, MD; Sa…
-
psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety
Sara J. Singer, MBA, PhD | September 1, 2013
View more articles from the same authors.
Citation Text:
Singer SJ. What We've Learned About Leveraging Leadership a…
-
psnet.ahrq.gov/node/49626/psn-pdf
May 01, 2011 - Outbreak
May 1, 2011
Rothman R, Stapleton S. Outbreak. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/outbreak
The Case
A 36-year-old healthy man developed an acute febrile illness associated with a vesicular rash. He
presented to an urgent care clinic where he was diagnosed with varicella infection ("chic…
-
psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - Right Electrocardiogram, Wrong Patient
March 25, 2020
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
The Cases
Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…
-
psnet.ahrq.gov/node/49628/psn-pdf
June 01, 2011 - Routine Goes Awry
June 1, 2011
Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/routine-goes-awry
The Case
A 6-year-old girl with a history of asthma and chronic adenotonsillitis was referred to a surgeon and
scheduled for a tonsillectomy and adenoidectomy. She was in ot…