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  1. Safe medication management at ambulatory surgery centers. | PSNet

    psnet.ahrq.gov/issue/safe-medication-management-ambulatory-surgery-centers
    December 14, 2016 - Commentary Safe medication management at ambulatory surgery centers. Citation Text: Ubaldi K. Safe Medication Management at Ambulatory Surgery Centers. AORN J. 2019;109(4):435-442. doi:10.1002/aorn.12635. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML…

  2. Health Care Quality and Disparities: Lessons from the First National Reports. | PSNet

    psnet.ahrq.gov/issue/health-care-quality-and-disparities-lessons-first-national-reports
    April 03, 2005 - Special or Theme Issue Health Care Quality and Disparities: Lessons from the First National Reports. Citation Text: Health Care Quality and Disparities: Lessons from the First National Reports. Kelley E, Moy E, Dayton E, et al. Med Care. 2005:43(3):I1-I88. Copy Citation …

  3. Safer by design. | PSNet

    psnet.ahrq.gov/issue/safer-design
    September 10, 2014 - Commentary Safer by design. Citation Text: Tonks A. Patient safety: Safer by design. BMJ. 2008;336(7637):186-8. doi:10.1136/bmj.39426.511759.AD. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downl…

  4. Agency information collection activities: Ambulatory Surgery Center Survey on Patient Safety Culture Database; comment request. | PSNet

    psnet.ahrq.gov/issue/agency-information-collection-activities-ambulatory-surgery-center-survey-patient-safety
    June 16, 2021 - Press Release/Announcement Agency information collection activities: Ambulatory Surgery Center Survey on Patient Safety Culture Database; comment request. Citation Text: Agency information collection activities: Ambulatory Surgery Center Survey on Patient Safety Culture Database; comment…

  5. Relationship of incorrect dosing of fibrinolytic therapy and clinical outcomes. | PSNet

    psnet.ahrq.gov/issue/relationship-incorrect-dosing-fibrinolytic-therapy-and-clinical-outcomes
    November 10, 2015 - Study Relationship of incorrect dosing of fibrinolytic therapy and clinical outcomes. Citation Text: Mehta RH. Relationship of Incorrect Dosing of Fibrinolytic Therapy and Clinical Outcomes. JAMA. 2005;293(14). doi:10.1001/jama.293.14.1746. Copy Citation Format: DOI Googl…

  6. Patient safety: it's not just carefulness, it's a culture. | PSNet

    psnet.ahrq.gov/issue/patient-safety-its-not-just-carefulness-its-culture
    December 24, 2008 - Commentary Patient safety: it's not just carefulness, it's a culture. Citation Text: Powell S. Patient Safety: it's not just carefulness, it's a culture. Lippincotts Case Manag. 2004;9(5):211-212. doi:10.1097/00129234-200409000-00001. Copy Citation Format: DOI Google Scho…

  7. Using fault trees to advance understanding of diagnostic errors. | PSNet

    psnet.ahrq.gov/issue/using-fault-trees-advance-understanding-diagnostic-errors
    November 11, 2020 - Commentary Using fault trees to advance understanding of diagnostic errors. Citation Text: Rogith D, Iyengar S, Singh H. Using Fault Trees to Advance Understanding of Diagnostic Errors. Jt Comm J Qual Patient Saf. 2017;43(11):598-605. doi:10.1016/j.jcjq.2017.06.007. Copy Citation F…

  8. Decision-making processes used by nurses during intravenous drug preparation and administration. | PSNet

    psnet.ahrq.gov/issue/decision-making-processes-used-nurses-during-intravenous-drug-preparation-and-administration
    June 29, 2022 - Study Decision-making processes used by nurses during intravenous drug preparation and administration. Citation Text: Dougherty L, Sque M, Crouch R. Decision-making processes used by nurses during intravenous drug preparation and administration. J Adv Nurs. 2012;68(6):1302-11. doi:10.1…

  9. Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety. | PSNet

    psnet.ahrq.gov/issue/fall-risk-and-prevention-agreement-engaging-patients-and-families-partnership-patient-safety
    November 13, 2024 - Commentary Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety. Citation Text: Vonnes C, Wolf D. Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety. BMJ Open Qual. 2017;6(2):e000038…

  10. Quality improvement and patient safety activities in academic departments of medicine. | PSNet

    psnet.ahrq.gov/issue/quality-improvement-and-patient-safety-activities-academic-departments-medicine
    July 02, 2014 - Study Quality improvement and patient safety activities in academic departments of medicine. Citation Text: Neeman N, Sehgal NL, Davis RB, et al. Quality improvement and patient safety activities in academic departments of medicine. Am J Med. 2012;125(8):831-5. doi:10.1016/j.amjmed.201…

  11. HIPAA and patient care: the role for professional judgment. | PSNet

    psnet.ahrq.gov/issue/hipaa-and-patient-care-role-professional-judgment
    June 22, 2022 - Commentary HIPAA and patient care: the role for professional judgment. Citation Text: Lo B, Dornbrand L, Dubler NN. HIPAA and patient care: the role for professional judgment. JAMA. 2005;293(14):1766-71. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML En…

  12. Evaluation of parenteral nutrition errors in an era of drug shortages. | PSNet

    psnet.ahrq.gov/issue/evaluation-parenteral-nutrition-errors-era-drug-shortages
    October 02, 2013 - Study Evaluation of parenteral nutrition errors in an era of drug shortages. Citation Text: Storey MA, Weber RJ, Besco K, et al. Evaluation of Parenteral Nutrition Errors in an Era of Drug Shortages. Nutr Clin Pract. 2016;31(2):211-7. doi:10.1177/0884533615608820. Copy Citation For…

  13. Beyond medication reconciliation: the correct medication list. | PSNet

    psnet.ahrq.gov/issue/beyond-medication-reconciliation-correct-medication-list
    February 15, 2017 - Commentary Beyond medication reconciliation: the correct medication list. Citation Text: Rose AJ, Fischer SH, Paasche-Orlow MK. Beyond Medication Reconciliation: The Correct Medication List. JAMA. 2017;317(20):2057-2058. doi:10.1001/jama.2017.4628. Copy Citation Format: DOI…

  14. Are we missing the near misses in the OR? Underreporting of safety incidents in pediatric surgery. | PSNet

    psnet.ahrq.gov/issue/are-we-missing-near-misses-or-underreporting-safety-incidents-pediatric-surgery
    October 05, 2022 - Study Are we missing the near misses in the OR? Underreporting of safety incidents in pediatric surgery. Citation Text: Hamilton EC, Pham DH, Minzenmayer AN, et al. Are we missing the near misses in the OR?-underreporting of safety incidents in pediatric surgery. J Surg Res. 2018;221:336…

  15. Interpretive error in radiology. | PSNet

    psnet.ahrq.gov/issue/interpretive-error-radiology
    August 01, 2018 - Commentary Interpretive error in radiology. Citation Text: Waite S, Scott JM, Gale B, et al. Interpretive Error in Radiology. AJR Am J Roentgenol. 2017;208(4):739-749. doi:10.2214/AJR.16.16963. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 …

  16. Can electronic clinical documentation help prevent diagnostic errors? | PSNet

    psnet.ahrq.gov/issue/can-electronic-clinical-documentation-help-prevent-diagnostic-errors
    December 02, 2020 - Commentary Can electronic clinical documentation help prevent diagnostic errors? Citation Text: Schiff G, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? New Engl J Med. 2010;362(12):1066-1069. doi:10.1056/NEJMp0911734. Copy Citation Format: …

  17. Assessing the performance of surgical teams. | PSNet

    psnet.ahrq.gov/issue/assessing-performance-surgical-teams
    July 05, 2017 - Study Assessing the performance of surgical teams. Citation Text: Leach LS, Myrtle RC, Weaver FA, et al. Assessing the performance of surgical teams. Health Care Manage Rev. 2009;34(1):29-41. doi:10.1097/01.HMR.0000342977.84307.64. Copy Citation Format: DOI Google Scholar…

  18. "Apologies" for pathologists: why, when, and how to say "sorry" after committing a medical error. | PSNet

    psnet.ahrq.gov/issue/apologies-pathologists-why-when-and-how-say-sorry-after-committing-medical-error
    September 04, 2024 - Commentary "Apologies" for pathologists: why, when, and how to say "sorry" after committing a medical error. Citation Text: Dewar R, Parkash V, Forrow L, et al. "Apologies" from pathologists: why, when, and how to say "sorry" after committing a medical error. Int J Surg Pathol. 2014;22(3…

  19. System weaknesses as contributing causes of accidents in health care. | PSNet

    psnet.ahrq.gov/issue/system-weaknesses-contributing-causes-accidents-health-care
    August 31, 2022 - Study System weaknesses as contributing causes of accidents in health care. Citation Text: Ternov S, Akselsson R. System weaknesses as contributing causes of accidents in health care. Int J Qual Health Care. 2005;17(1):5-13. Copy Citation Format: Google Scholar PubMed Bib…

  20. Achieving the 'perfect handoff' in patient transfers: building teamwork and trust. | PSNet

    psnet.ahrq.gov/issue/achieving-perfect-handoff-patient-transfers-building-teamwork-and-trust
    October 08, 2016 - Commentary Achieving the 'perfect handoff' in patient transfers: building teamwork and trust. Citation Text: Clarke D, Werestiuk K, Schoffner A, et al. Achieving the 'perfect handoff' in patient transfers: building teamwork and trust. J Nurs Manag. 2012;20(5):592-8. doi:10.1111/j.1365-…
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