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  1. Medication orders with future start dates: how far away is too far? | PSNet

    psnet.ahrq.gov/issue/medication-orders-future-start-dates-how-far-away-too-far
    March 15, 2022 - Newspaper/Magazine Article Medication orders with future start dates: how far away is too far? Citation Text: Medication orders with future start dates: how far away is too far? ISMP Medication Safety Alert! Acute care edition. July 14, 2022:27(14):1-4. Copy Citation Sa…

  2. Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. | PSNet

    psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone-overdose
    June 03, 2020 - Newspaper/Magazine Article Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. Citation Text: Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. ISMP Medication Safety Alert! Acute care edition. May 7…

  3. Can teamwork promote safety in organizations? | PSNet

    psnet.ahrq.gov/issue/can-teamwork-promote-safety-organizations
    April 24, 2019 - Review Emerging Classic Can teamwork promote safety in organizations? Citation Text: Salas E, Bisbey TM, Traylor AM, et al. Can teamwork promote safety in organizations? . Ann Rev Org Psychol Org Behav. 2020;7(1):283-313. doi:10.1146/annurev-orgpsych-012119-0454…

  4. An evaluation of information transfer through the continuum of surgical care: a feasibility study. | PSNet

    psnet.ahrq.gov/issue/evaluation-information-transfer-through-continuum-surgical-care-feasibility-study
    December 21, 2014 - Study An evaluation of information transfer through the continuum of surgical care: a feasibility study. Citation Text: Nagpal K, Vats A, Ahmed K, et al. An evaluation of information transfer through the continuum of surgical care: a feasibility study. Ann Surg. 2010;252(2):402-7. doi:1…

  5. The power of collaboration with patient safety programs: building safe passage for patients, nurses, and clinical staff. | PSNet

    psnet.ahrq.gov/issue/power-collaboration-patient-safety-programs-building-safe-passage-patients-nurses-and
    April 21, 2021 - Commentary The power of collaboration with patient safety programs: building safe passage for patients, nurses, and clinical staff. Citation Text: Kerfoot KM, Rapala K, Ebright PR, et al. The power of collaboration with patient safety programs: building safe passage for patients, nurse…

  6. Early readmissions to the department of medicine as a screening tool for monitoring quality of care problems. | PSNet

    psnet.ahrq.gov/issue/early-readmissions-department-medicine-screening-tool-monitoring-quality-care-problems
    April 06, 2022 - Study Early readmissions to the department of medicine as a screening tool for monitoring quality of care problems. Citation Text: Balla U, Malnick S, Schattner A. Early readmissions to the department of medicine as a screening tool for monitoring quality of care problems. Medicine (Ba…

  7. Patient involvement in patient safety: a qualitative study of nursing staff and patient perceptions. | PSNet

    psnet.ahrq.gov/issue/patient-involvement-patient-safety-qualitative-study-nursing-staff-and-patient-perceptions
    March 02, 2016 - Study Patient involvement in patient safety: a qualitative study of nursing staff and patient perceptions. Citation Text: Bishop A, Macdonald M. Patient Involvement in Patient Safety: A Qualitative Study of Nursing Staff and Patient Perceptions. J Patient Saf. 2017;13(2):82-87. doi:10.10…

  8. Database construction for improving patient safety by examining pathology errors.   | PSNet

    psnet.ahrq.gov/issue/database-construction-improving-patient-safety-examining-pathology-errors
    December 22, 2008 - Commentary Database construction for improving patient safety by examining pathology errors.   Citation Text: Grzybicki DM, Turcsany B, Becich MJ, et al. Database Construction for Improving Patient Safety by Examining Pathology Errors. Am J Clin Pathol. 2008;124(4). doi:10.1309/xn25jg7…

  9. To err is human, but what happens when surgeons err? | PSNet

    psnet.ahrq.gov/issue/err-human-what-happens-when-surgeons-err
    August 04, 2021 - Study To err is human, but what happens when surgeons err? Citation Text: Lin JS, Olutoye OO, Samora JB. To err is human, but what happens when surgeons err? J Pediatr Surg. 2023;58(3):496-502. doi:10.1016/j.jpedsurg.2022.06.019. Copy Citation Format: DOI Google Scholar Bib…

  10. Patient safety knowledge and its determinants in medical trainees. | PSNet

    psnet.ahrq.gov/issue/patient-safety-knowledge-and-its-determinants-medical-trainees
    July 29, 2020 - Study Patient safety knowledge and its determinants in medical trainees. Citation Text: Kerfoot P, Conlin PR, Travison T, et al. Patient safety knowledge and its determinants in medical trainees. J Gen Intern Med. 2007;22(8):1150-4. Copy Citation Format: Google Scholar Pu…

  11. Managing health IT risks: reflections and recommendations. | PSNet

    psnet.ahrq.gov/issue/managing-health-it-risks-reflections-and-recommendations
    July 10, 2024 - Commentary Managing health IT risks: reflections and recommendations. Citation Text: Sujan M. Managing health IT risks: reflections and recommendations. J Innov Health Inform. 2018;25(1):952. doi:10.14236/jhi.v25i1.952. Copy Citation Format: DOI Google Scholar PubMed BibTeX…

  12. Directed peer review in surgical pathology. | PSNet

    psnet.ahrq.gov/issue/directed-peer-review-surgical-pathology
    December 03, 2014 - Commentary Directed peer review in surgical pathology. Citation Text: Smith ML, Raab SS. Directed peer review in surgical pathology. Adv Anat Pathol. 2012;19(5):331-337. doi:10.1097/pap.0b013e31826661b7. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote…

  13. Error tracking in a clinical biochemistry laboratory. | PSNet

    psnet.ahrq.gov/issue/error-tracking-clinical-biochemistry-laboratory
    June 10, 2020 - Study Error tracking in a clinical biochemistry laboratory. Citation Text: Szecsi PB, Ødum L. Error tracking in a clinical biochemistry laboratory. Clin Chem Lab Med. 2009;47(10). doi:10.1515/cclm.2009.272. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML End…

  14. A unified model of patient safety (or "Who froze my cheese?"). | PSNet

    psnet.ahrq.gov/issue/unified-model-patient-safety-or-who-froze-my-cheese
    August 23, 2023 - Commentary A unified model of patient safety (or "Who froze my cheese?"). Citation Text: Coiera E, Collins S, Kuziemsky C. A unified model of patient safety (or "Who froze my cheese?"). BMJ. 2013;347:f7273. doi:10.1136/bmj.f7273. Copy Citation Format: DOI Google Scholar …

  15. Creating an oversight infrastructure for electronic health record–related patient safety hazards. | PSNet

    psnet.ahrq.gov/issue/creating-oversight-infrastructure-electronic-health-record-related-patient-safety-hazards
    May 22, 2015 - Commentary Creating an oversight infrastructure for electronic health record–related patient safety hazards. Citation Text: Singh H, Classen D, Sittig DF. Creating an oversight infrastructure for electronic health record-related patient safety hazards. J Patient Saf. 2011;7(4):169-74. …

  16. "Going solid": a model of system dynamics and consequences for patient safety. | PSNet

    psnet.ahrq.gov/issue/going-solid-model-system-dynamics-and-consequences-patient-safety
    August 01, 2018 - Commentary Classic "Going solid": a model of system dynamics and consequences for patient safety. Citation Text: Cook R, Rasmussen J. "Going solid": a model of system dynamics and consequences for patient safety. Qual Saf Health Care. 2005;14(2):130-4. Copy …

  17. Seeking high reliability in primary care: leadership, tools, and organization. | PSNet

    psnet.ahrq.gov/issue/seeking-high-reliability-primary-care-leadership-tools-and-organization
    October 13, 2018 - Study Seeking high reliability in primary care: leadership, tools, and organization. Citation Text: Weaver RR. Seeking high reliability in primary care: Leadership, tools, and organization. Health Care Manage Rev. 2015;40(3):183-92. doi:10.1097/HMR.0000000000000022. Copy Citation F…

  18. Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites. | PSNet

    psnet.ahrq.gov/issue/diagnostic-errors-interpretation-pediatric-musculoskeletal-radiographs-common-injury-sites
    August 02, 2015 - Study Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites. Citation Text: Bisset GS, Crowe J. Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites. Pediatr Radiol. 2014;44(5):552-7. doi:10.1007…

  19. Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. | PSNet

    psnet.ahrq.gov/issue/indian-health-service-actions-needed-improve-use-data-adverse-events
    September 07, 2016 - Book/Report Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. Citation Text: Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. Washington, DC: United States Government Accounting Office; July 10, 2023.  Publication GAO-23-1…

  20. Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. | PSNet

    psnet.ahrq.gov/issue/developing-indicators-inpatient-adverse-drug-events-through-nonlinear-analysis-using
    December 23, 2011 - Study Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. Citation Text: Nebeker JR, Yarnold PR, Soltysik RC, et al. Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. Med…
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