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psnet.ahrq.gov/issue/how-us-teams-advanced-communication-and-resolution-program-adoption-local-state-and-national
April 24, 2018 - Study
How U.S. teams advanced communication and resolution program adoption at local, state and national levels.
Citation Text:
LeCraw FR, Stearns SC, McCoy MJ. How U.S. Teams advanced communication and resolution program adoption at local, state and national levels. J Patient Saf Risk M…
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psnet.ahrq.gov/issue/what-do-family-physicians-consider-error-comparison-definitions-and-physician-perception
February 15, 2011 - Study
What do family physicians consider an error? A comparison of definitions and physician perception.
Citation Text:
Elder NC, Pallerla H, Regan S. What do family physicians consider an error? A comparison of definitions and physician perception. BMC Fam Pract. 2006;7:73.
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psnet.ahrq.gov/issue/direct-oral-anticoagulants-review-common-medication-errors
January 12, 2022 - Review
Emerging Classic
Direct oral anticoagulants: a review of common medication errors.
Citation Text:
Barr D, Epps QJ. Direct oral anticoagulants: a review of common medication errors. J Thromb Thrombolysis. 2019;47(1):146-154. doi:10.1007/s11239-018-1752-9. …
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psnet.ahrq.gov/issue/what-are-we-doing-when-we-double-check
June 10, 2020 - Commentary
What are we doing when we double check?
Citation Text:
Pfeiffer Y, Zimmermann C, Schwappach DLB. What are we doing when we double check? BMJ Qual Saf. 2020;29(7):536-540. doi:10.1136/bmjqs-2019-009680.
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psnet.ahrq.gov/issue/older-peoples-experiences-medicine-changes-leaving-hospital
August 26, 2020 - Study
Older people's experiences of medicine changes on leaving hospital.
Citation Text:
Bagge M, Norris P, Heydon S, et al. Older people's experiences of medicine changes on leaving hospital. Res Social Admin Pharm. 2013;10(5):791-800. doi:10.1016/j.sapharm.2013.10.005.
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psnet.ahrq.gov/issue/patient-safety-home-health-care-grounded-theory-study
September 25, 2019 - Study
Patient safety in home health care: a grounded theory study.
Citation Text:
Shahrestanaki SK, Rafii F, Najafi Ghezeljeh T, et al. Patient safety in home health care: a grounded theory study. BMC Health Serv Res. 2023;23(1):467. doi:10.1186/s12913-023-09458-9.
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psnet.ahrq.gov/issue/team-disclosure-error-educational-activity-objective-outcomes
January 31, 2018 - Study
A team disclosure of error educational activity: objective outcomes.
Citation Text:
Krumwiede KH, Wagner JM, Kirk LM, et al. A Team Disclosure of Error Educational Activity: Objective Outcomes. J Am Geriatr Soc. 2019;67(6):1273-1277. doi:10.1111/jgs.15883.
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psnet.ahrq.gov/issue/healthcare-professionals-encounters-ethnic-minority-patients-critical-incident-approach
July 29, 2020 - Study
Healthcare professionals' encounters with ethnic minority patients: the critical incident approach.
Citation Text:
Debesay J, Kartzow AH, Fougner M. Healthcare professionals’ encounters with ethnic minority patients: the critical incident approach. Nurs Inq. 2021;29(1):e12421. doi:…
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psnet.ahrq.gov/issue/discrepant-advanced-directives-and-code-status-orders-preventable-medical-error
October 31, 2018 - Journal Article
Discrepant advanced directives and code status orders: a preventable medical error.
Citation Text:
Meisenberg B, Zaidi S, Franks L, et al. Discrepant Advanced Directives and Code Status Orders: A Preventable Medical Error. J Hosp Med. 2019;14(10):716-718. doi:10.12788/jhm…
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psnet.ahrq.gov/issue/wear-face-masks-no-metal-during-mri-exams
April 08, 2020 - Press Release/Announcement
Wear face masks with no metal during MRI exams.
Citation Text:
Wear face masks with no metal during MRI exams. FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 7, 2020.
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psnet.ahrq.gov/issue/factors-affecting-patient-safety-culture-among-dental-healthcare-workers-nationwide-cross
June 16, 2021 - Study
Factors affecting patient safety culture among dental healthcare workers: A nationwide cross-sectional survey
Citation Text:
Cheng H-C, Yen AM-F, Lee Y-H. Factors affecting patient safety culture among dental healthcare workers: A nationwide cross-sectional survey. J Dent Sci. 2019…
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psnet.ahrq.gov/issue/addressing-opioid-epidemic-united-states-lessons-department-veterans-affairs
September 07, 2022 - Commentary
Classic
Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs.
Citation Text:
Gellad WF, Good CB, Shulkin DJ. Addressing the Opioid Epidemic in the United States: Lessons From the Department of Veterans A…
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psnet.ahrq.gov/issue/use-simulation-emergency-medicine-research-agenda
December 30, 2008 - Commentary
The use of simulation in emergency medicine: a research agenda.
Citation Text:
Bond WF, Lammers RL, Spillane LL, et al. The use of simulation in emergency medicine: a research agenda. Acad Emerg Med. 2007;14(4):353-63.
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psnet.ahrq.gov/issue/linking-joint-commission-inpatient-core-measures-and-national-patient-safety-goals-evidence
October 19, 2022 - Commentary
Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence.
Citation Text:
Masica AL, Richter KM, Convery P, et al. Linking joint commission inpatient core measures and national patient safety goals with evidence. Proc (Bayl Univ Med Cen…
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psnet.ahrq.gov/issue/provider-and-pharmacist-responses-warfarin-drug-drug-interaction-alerts-study-healthcare
July 29, 2020 - Study
Provider and pharmacist responses to warfarin drug–drug interaction alerts: a study of healthcare downstream of CPOE alerts.
Citation Text:
Miller AM, Boro MS, Korman NE, et al. Provider and pharmacist responses to warfarin drug-drug interaction alerts: a study of healthcare downst…
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psnet.ahrq.gov/issue/patient-safety-inpatient-psychiatry-remaining-frontier-health-policy
October 19, 2022 - Commentary
Patient safety in inpatient psychiatry: a remaining frontier for health policy.
Citation Text:
Shields MC, Stewart MT, Delaney KR. Patient Safety In Inpatient Psychiatry: A Remaining Frontier For Health Policy. Health Aff (Millwood). 2018;37(11):1853-1861. doi:10.1377/hlthaff.…
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psnet.ahrq.gov/issue/flaw-medicine-addressing-racial-and-gender-disparities-critical-care
June 16, 2010 - Commentary
The flaw of medicine: addressing racial and gender disparities in critical care.
Citation Text:
Hilton EJ, Goff KL, Sreedharan R, et al. The flaw of medicine: addressing racial and gender disparities in critical care. Anesthesiol Clin. 2020;38(2):357-368. doi:10.1016/j.anclin.…
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psnet.ahrq.gov/issue/effect-rapid-response-team-incidence-hospital-mortality
March 15, 2023 - Study
Effect of a rapid response team on the incidence of in-hospital mortality.
Citation Text:
Factora F, Maheshwari K, Khanna S, et al. Effect of a rapid response team on the incidence of in-hospital mortality. Anesth Analg. 2022;135(3):595-604. doi:10.1213/ane.0000000000006005.
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psnet.ahrq.gov/issue/more-words-interpersonal-communication-cognitive-bias-and-diagnostic-errors
March 11, 2013 - Commentary
'More than words' - interpersonal communication, cognitive bias and diagnostic errors.
Citation Text:
Dahm MR, Williams M, Crock C. ‘More than words’ – Interpersonal communication, cognitive bias and diagnostic errors. Patient Educ Couns. 2022;105(1):252-256. doi:10.1016/j.pec…
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psnet.ahrq.gov/issue/frequency-and-severity-parenteral-nutrition-medication-errors-large-childrens-hospital-after
April 11, 2011 - Study
Frequency and severity of parenteral nutrition medication errors at a large children's hospital after implementation of electronic ordering and compounding.
Citation Text:
MacKay M, Anderson C, Boehme S, et al. Frequency and Severity of Parenteral Nutrition Medication Errors at a L…