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psnet.ahrq.gov/issue/finding-blunders-thyroid-testing-experience-newborns
March 04, 2020 - Study
Finding blunders in thyroid testing: experience in newborns.
Citation Text:
Zilka LJ, Lott JA, Baker LC, et al. Finding blunders in thyroid testing: experience in newborns. J Clin Lab Anal. 2008;22(4):254-6. doi:10.1002/jcla.20247.
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psnet.ahrq.gov/issue/hospital-readmissions-reduction-program-implications-pharmacy
September 23, 2020 - Commentary
Hospital Readmissions Reduction Program: implications for pharmacy.
Citation Text:
Boesen KAG, Leal S, Sheehan VC, et al. Hospital Readmissions Reduction Program: implications for pharmacy. Am J Health Syst Pharm. 2015;72(3):237-44. doi:10.2146/ajhp140177.
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psnet.ahrq.gov/issue/introducing-new-technology-operating-room-measuring-impact-job-performance-and-satisfaction
May 18, 2022 - Study
Introducing new technology into the operating room: measuring the impact on job performance and satisfaction.
Citation Text:
Stahl JE, Egan MT, Goldman JM, et al. Introducing new technology into the operating room: measuring the impact on job performance and satisfaction. Surgery…
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psnet.ahrq.gov/issue/errors-and-burden-errors-attitudes-perceptions-and-culture-safety-pediatric-cardiac-surgical
June 16, 2019 - Study
Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams.
Citation Text:
Bognár A, Barach P, Johnson J, et al. Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac sur…
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psnet.ahrq.gov/issue/organisational-failure-rethinking-whistleblowing-tomorrows-doctors
May 18, 2022 - Commentary
Organisational failure: rethinking whistleblowing for tomorrow's doctors.
Citation Text:
Taylor DJ, Goodwin D. Organisational failure: rethinking whistleblowing for tomorrow’s doctors. J Med Ethics. 2022;48(10):672-677. doi:10.1136/jme-2022-108328.
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psnet.ahrq.gov/node/39283/psn-pdf
December 21, 2014 - Parents' medication administration errors: role of dosing
instruments and health literacy.
December 21, 2014
Yin S, Mendelsohn A, Wolf MS, et al. Parents' medication administration errors: role of dosing instruments
and health literacy. Arch Pediatr Adolesc Med. 2010;164(2):181-6. doi:10.1001/archpediatrics.2009.26…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.236_slideshow.ppt
March 01, 2011 - Spotlight Case July 2008
Spotlight Case March 2011
Volume Too Low: In and Out
Pediatric Patient Safety
*
*
Source and Credits
This presentation is based on the March 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Marlene Miller, MD, MSc…
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psnet.ahrq.gov/node/49621/psn-pdf
March 01, 2011 - Volume Too Low: In and Out
March 1, 2011
Miller MR. Volume Too Low: In and Out . PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/volume-too-low-and-out
Case Objectives
Appreciate that because of multiple factors, children are at high risk for medical errors.
Describe the importance of weight-based dosing of…
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psnet.ahrq.gov/web-mm/its-sarah-not-stephen
January 01, 2015 - SPOTLIGHT CASE
It's Sarah, Not Stephen!
Citation Text:
Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/issue/translating-patient-safety-legislation-health-care-practice
February 15, 2011 - Commentary
Translating patient safety legislation into health care practice.
Citation Text:
Rabinowitz ABK, Clarke JR, Marella WM, et al. Translating patient safety legislation into health care practice. Jt Comm J Qual Patient Saf. 2006;32(12):676-681.
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psnet.ahrq.gov/issue/benefits-and-opportunities-engaging-patients-identifying-and-reporting-patient-safety
April 26, 2023 - Commentary
The benefits and opportunities: engaging patients in identifying and reporting patient safety incidents.
Citation Text:
Pozzobon LD, Rotter T, Sears K. The benefits and opportunities: engaging patients in identifying and reporting patient safety incidents. Healthc Manage Forum…
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psnet.ahrq.gov/issue/diagnostic-time-out-improve-differential-diagnosis-pediatric-abdominal-pain
February 10, 2021 - Study
A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain.
Citation Text:
Kasick RT, Melvin JE, Perera ST, et al. A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain. Diagnosis (Berl). 2021;8(2):209-217. doi:10.1515/dx-2019-…
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psnet.ahrq.gov/issue/long-term-sustainability-and-adaptation-i-pass-handovers
September 09, 2020 - Study
Long-term sustainability and adaptation of I-PASS handovers.
Citation Text:
Ryan SL, Logan M, Liu X, et al. Long-term sustainability and adaptation of I-PASS handovers. Jt Comm J Qual Patient Saf. 2023;19(12):689-697. doi:10.1016/j.jcjq.2023.07.007.
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…
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psnet.ahrq.gov/issue/critical-issues-food-allergy-national-academies-consensus-report
November 16, 2022 - Commentary
Critical Issues in Food Allergy: A National Academies Consensus Report.
Citation Text:
Sicherer SH, Allen K, Lack G, et al. Critical Issues in Food Allergy: A National Academies Consensus Report. Pediatrics. 2017;140(2). doi:10.1542/peds.2017-0194.
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psnet.ahrq.gov/issue/delineation-risk-through-exploration-culture-safety-community-home-health
December 04, 2016 - Study
Delineation of risk through the exploration of a culture of safety in community home health.
Citation Text:
Stevenson L, McRae C, Mughal WA. Delineation of Risk Through the Exploration of a Culture of Safety in Community Home Health. Home Health Care Manag Pract. 2007;19(6). doi:…
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psnet.ahrq.gov/issue/hospital-do-not-resuscitate-orders-why-they-have-failed-and-how-fix-them
May 13, 2009 - Review
Hospital do-not-resuscitate orders: why they have failed and how to fix them.
Citation Text:
Yuen JK, Reid C, Fetters MD. Hospital do-not-resuscitate orders: why they have failed and how to fix them. J Gen Intern Med. 2011;26(7):791-7. doi:10.1007/s11606-011-1632-x.
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psnet.ahrq.gov/issue/communicating-gray-zone-perceptions-about-emergency-physician-hospitalist-handoffs-and
March 17, 2010 - Study
Communicating in the "gray zone": perceptions about emergency physician-hospitalist handoffs and patient safety.
Citation Text:
Apker J, Mallak LA, Gibson SC. Communicating in the "gray zone": perceptions about emergency physician hospitalist handoffs and patient safety. Acad Eme…
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psnet.ahrq.gov/issue/new-graduate-registered-nurses-knowledge-patient-safety-and-practice-literature-review
June 13, 2018 - Review
New graduate registered nurses' knowledge of patient safety and practice: a literature review.
Citation Text:
Murray M, Sundin D, Cope V. New graduate registered nurses' knowledge of patient safety and practice: A literature review. J Clin Nurs. 2018;27(1-2):31-47. doi:10.1111/joc…
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psnet.ahrq.gov/issue/gaps-pediatric-clinician-communication-and-opportunities-improvement
March 24, 2011 - Study
Gaps in pediatric clinician communication and opportunities for improvement.
Citation Text:
Woods D, Holl JL, Angst DB, et al. Gaps in pediatric clinician communication and opportunities for improvement. J Healthc Qual. 2008;30(5):43-54.
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psnet.ahrq.gov/issue/nexus-nursing-leadership-and-culture-safer-patient-care
January 18, 2018 - Review
The nexus of nursing leadership and a culture of safer patient care.
Citation Text:
Murray M, Sundin D, Cope V. The nexus of nursing leadership and a culture of safer patient care. J Clin Nurs. 2018;27(5-6):1287-1293. doi:10.1111/jocn.13980.
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