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9701. Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. | PSNet
      psnet.ahrq.gov/issue/doctors-make-mistakes-new-documentary-explores-what-happens-when-they-do-and-how-fix-it
      November 20, 2019 - Newspaper/Magazine Article Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. Citation Text: Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. Park A. Time Magazine. January 24, 2019. Copy Citation…

9702. Improving Diagnostic Quality and Safety Final Report. | PSNet
      psnet.ahrq.gov/issue/improving-diagnostic-quality-and-safety-final-report
      September 06, 2011 - Book/Report Classic Improving Diagnostic Quality and Safety Final Report. Citation Text: Improving Diagnostic Quality and Safety Final Report. Washington, DC: National Quality Forum. September 19, 2017. Copy Citation Save Save to your lib…

9703. Understanding and Improving Diagnostic Safety in Ambulatory Care. | PSNet
      psnet.ahrq.gov/issue/understanding-and-improving-diagnostic-safety-ambulatory-care
      August 17, 2022 - Grant Announcement Understanding and Improving Diagnostic Safety in Ambulatory Care. Citation Text: Understanding and Improving Diagnostic Safety in Ambulatory Care. Rockville, MD: Agency for Healthcare Quality and Research; August 22, 2023. Copy Citation Save S…

9704. System failure versus personal accountability--the case for clean hands. | PSNet
      psnet.ahrq.gov/issue/system-failure-versus-personal-accountability-case-clean-hands
      February 16, 2011 - Commentary System failure versus personal accountability--the case for clean hands. Citation Text: Goldmann DA. System failure versus personal accountability--the case for clean hands. N Engl J Med. 2006;355(2):121-3. Copy Citation Format: Google Scholar PubMed BibTeX End…

9705. Cultivate discussions in a psychologically safe workplace: part 1 and part II. | PSNet
      psnet.ahrq.gov/issue/cultivate-discussions-psychologically-safe-workplace-part-1-and-part-ii
      August 11, 2021 - Special or Theme Issue Cultivate discussions in a psychologically safe workplace: part 1 and part II. Citation Text: Cultivate discussions in a psychologically safe workplace: part 1 and part II. ISMP Medication Safety Alert! Acute Care. July 11, 2024;29;(14):1-3; July 25, 2024;29(15):1-…

9706. Using the ISMP Medication Safety Self-Assessment to improve medication use processes. | PSNet
      psnet.ahrq.gov/issue/using-ismp-medication-safety-self-assessment-improve-medication-use-processes
      January 05, 2017 - Study Using the ISMP Medication Safety Self-Assessment to improve medication use processes. Citation Text: Lesar TS, Mattis A, Anderson E, et al. Using the ISMP Medication Safety Self-Assessment to improve medication use processes. Jt Comm J Qual Saf. 2003;29(5):211-26. Copy Citation …

9707. Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm. | PSNet
      psnet.ahrq.gov/issue/mix-ups-between-epidural-analgesia-and-iv-antibiotics-labor-and-delivery-units-continue-cause
      January 24, 2018 - Newspaper/Magazine Article Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm. Citation Text: Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm. ISMP Medication Safety Alert! Acut…

9708. Health IT Hazard Manager Beta-Test Appendix B: Revised Hazard Manager Ontology (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/AppendixB_HIT_Hazard_Manager_Beta_Test.pdf
      June 16, 2021 - Health IT Hazard Manager Beta-Test Appendix B: Revised Hazard Manager Ontology Appendix B – Revised Hazard Manager Ontology Hazard Manager Common Formats Usability • Information hard to find • Difficult data entry • Excessive demands on human memory • Sub-optimal support of teamwork (situation awareness) • C…

9709. Dermatology faces a reckoning: lack of darker skin in textbooks and journals harms care for patients of color. | PSNet
      psnet.ahrq.gov/issue/dermatology-faces-reckoning-lack-darker-skin-textbooks-and-journals-harms-care-patients-color
      February 14, 2024 - Newspaper/Magazine Article Dermatology faces a reckoning: lack of darker skin in textbooks and journals harms care for patients of color. Citation Text: Dermatology faces a reckoning: lack of darker skin in textbooks and journals harms care for patients of color. McFarling UL. Stat.…

9710. Help your patient "get" what you just said: a health literacy guide. | PSNet
      psnet.ahrq.gov/issue/help-your-patient-get-what-you-just-said-health-literacy-guide
      December 18, 2014 - Commentary Help your patient "get" what you just said: a health literacy guide. Citation Text: Roett MA, Wessel L. Help your patient "get" what you just said: a health literacy guide. J Family Pract. 2012;61(4):190-196. Copy Citation Format: Google Scholar PubMed BibTeX E…

9711. Errors in a stat laboratory: changes in type and frequency since 1996. | PSNet
      psnet.ahrq.gov/issue/errors-stat-laboratory-changes-type-and-frequency-1996
      December 21, 2016 - Study Errors in a stat laboratory: changes in type and frequency since 1996. Citation Text: Carraro P, Plebani M. Errors in a stat laboratory: types and frequencies 10 years later. Clin Chem. 2007;53(7):1338-42. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X…

9712. The quality and economic impact of disruptive behaviors on clinical outcomes of patient care. | PSNet
      psnet.ahrq.gov/issue/quality-and-economic-impact-disruptive-behaviors-clinical-outcomes-patient-care
      February 03, 2010 - Commentary The quality and economic impact of disruptive behaviors on clinical outcomes of patient care. Citation Text: Rosenstein AH. The quality and economic impact of disruptive behaviors on clinical outcomes of patient care. Am J Med Qual. 2011;26(5):372-9. doi:10.1177/106286061140…

9713. AHRQ announces interest in research on health IT safety. | PSNet
      psnet.ahrq.gov/issue/ahrq-announces-interest-research-health-it-safety
      August 15, 2018 - Press Release/Announcement AHRQ announces interest in research on health IT safety. Citation Text: AHRQ announces interest in research on health IT safety. Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. March 9, 2016. Publication No. NOT-HS-16-009. …

9714. Interruptions in healthcare: theoretical views. | PSNet
      psnet.ahrq.gov/issue/interruptions-healthcare-theoretical-views
      September 24, 2016 - Review Interruptions in healthcare: theoretical views. Citation Text: Grundgeiger T, Sanderson P. Interruptions in healthcare: theoretical views. Int J Med Inform. 2009;78(5):293-307. doi:10.1016/j.ijmedinf.2008.10.001. Copy Citation Format: DOI Google Scholar PubMed BibTeX…

9715. Work-arounds in health care settings: literature review and research agenda. | PSNet
      psnet.ahrq.gov/issue/work-arounds-health-care-settings-literature-review-and-research-agenda
      October 02, 2013 - Review Work-arounds in health care settings: literature review and research agenda. Citation Text: Halbesleben JRB, Wakefield DS, Wakefield BJ. Work-arounds in health care settings: literature review and research agenda. Health Care Manage Rev. 2008;33(1):2-12. doi:10.1097/01.hmr.0000304…

9716. Josie's Story: A Patient Safety Curriculum. | PSNet
      psnet.ahrq.gov/issue/josies-story-patient-safety-curriculum
      July 24, 2019 - Toolkit Josie's Story: A Patient Safety Curriculum. Citation Text: Josie's Story: A Patient Safety Curriculum. Kaprielian VS, Sullivan DT, eds. Chapel Hill, NC: Josie King Foundation; Duke University School of Medicine; 2013. Copy Citation Save Save to your librar…

9717. Patient Safety: Achieving a New Standard for Care. | PSNet
      psnet.ahrq.gov/issue/patient-safety-achieving-new-standard-care
      January 04, 2009 - Book/Report Patient Safety: Achieving a New Standard for Care. Citation Text: Patient Safety: Achieving a New Standard for Care. Aspden P ed, Committee for Data Standards for Patient Safety, Institute of Medicine. Washington DC: National Academies Press; 2004. ISBN 0309090776. Copy…

9718. Crew resource management: applications in healthcare organizations. | PSNet
      psnet.ahrq.gov/issue/crew-resource-management-applications-healthcare-organizations
      November 10, 2021 - Commentary Crew resource management: applications in healthcare organizations. Citation Text: Oriol MD. Crew resource management: applications in healthcare organizations. J Nurs Adm. 2006;36(9):402-406. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML En…

9719. When a nurse is prosecuted for a fatal medical mistake, does it make medicine safer? | PSNet
      psnet.ahrq.gov/issue/when-nurse-prosecuted-fatal-medical-mistake-does-it-make-medicine-safer
      March 13, 2019 - Newspaper/Magazine Article When a nurse is prosecuted for a fatal medical mistake, does it make medicine safer? Citation Text: When a nurse is prosecuted for a fatal medical mistake, does it make medicine safer? Gordon M. Health Shots. National Public Radio. April 10, 2019. Copy Citati…

9720. Errors originating in hospital and health-system outpatient pharmacies. | PSNet
      psnet.ahrq.gov/issue/errors-originating-hospital-and-health-system-outpatient-pharmacies
      December 19, 2016 - Newspaper/Magazine Article Errors originating in hospital and health-system outpatient pharmacies. Citation Text: Errors originating in hospital and health-system outpatient pharmacies. Straka M, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. June 2017;14:55-63. Copy Citation …