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Bad Writing, Wrong Medication | PSNet

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March 01, 2015 - SPOTLIGHT CASE Bad Writing, Wrong Medication Citation Text: Devine B. Bad Writing, Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3…

Organizational Learning | PSNet

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September 15, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Organizational Learning Download Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team…

Annual Perspective: Psychological Safety of Healthcare Staff | PSNet

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November 16, 2022 - Annual Perspective Annual Perspective: Psychological Safety of Healthcare Staff March 31, 2022 View more articles from the same authors. Citation Text: Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. P…

Communication During Transitions of Care | PSNet

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July 10, 2024 - Annual Perspective Communication During Transitions of Care Ayse P. Gurses; Sarah Mossburg; Zoe Sousane | March 27, 2024 View more articles from the same authors. Citation Text: Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PS…

Verbal Orders and Medication Overrides: A Dangerous Combination | PSNet

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September 27, 2023 - Verbal Orders and Medication Overrides: A Dangerous Combination Citation Text: Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…

Why Things Bite Back: Technology and the Revenge of Unintended Consequences. | PSNet

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March 20, 2019 - Book/Report Classic Why Things Bite Back: Technology and the Revenge of Unintended Consequences. Citation Text: Why Things Bite Back: Technology and the Revenge of Unintended Consequences. Tenner E. New York, NY: Knopf; 1996. ISBN: 0679425632. Copy Citation …

Quantification and classification of errors associated with hand-repackaging of medications in long-term care facilities in Germany. | PSNet

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April 21, 2021 - Study Quantification and classification of errors associated with hand-repackaging of medications in long-term care facilities in Germany. Citation Text: Gerber A, Kohaupt I, Lauterbach KW, et al. Quantification and classification of errors associated with hand-repackaging of medicat…

Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. | PSNet

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February 23, 2022 - Study Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. Citation Text: Cohen AL, Sur M, Falco C, et al. Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. Diagnosis (Berl). 2022;9(4):476-484. doi:10.1515/dx-20…

Bridging the gap between culture and safety in a critical care context: the role of work debate spaces. | PSNet

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July 15, 2020 - Study Bridging the gap between culture and safety in a critical care context: the role of work debate spaces. Citation Text: Leuridan G. Bridging the gap between culture and safety in a critical care context: the role of work debate spaces. Safety Sci. 2020;129:104839. doi:10.1016/j.ssci…

Use of error management theory to quantify and characterize residents' error recovery strategies. | PSNet

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June 14, 2023 - Study Use of error management theory to quantify and characterize residents' error recovery strategies. Citation Text: Pugh CM, Law KE, Cohen ER, et al. Use of error management theory to quantify and characterize residents’ error recovery strategies. Am J Surg. 2020;219(2):214-220. doi:1…

Adverse diagnostic events in hospitalised patients: a single-centre, retrospective cohort study. | PSNet

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December 07, 2022 - Study Adverse diagnostic events in hospitalised patients: a single-centre, retrospective cohort study. Citation Text: Dalal AK, Plombon S, Konieczny K, et al. Adverse diagnostic events in hospitalised patients: a single-centre, retrospective cohort study. BMJ Qual Saf. 2024;Epub Oct 1. d…

Developing and implementing new safe practices: voluntary adoption through statewide collaboratives. | PSNet

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June 13, 2011 - Commentary Developing and implementing new safe practices: voluntary adoption through statewide collaboratives. Citation Text: Leape L, Rogers G, Hanna D, et al. Developing and implementing new safe practices: voluntary adoption through statewide collaboratives. Qual Saf Health Care. 2…

Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions. | PSNet

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October 04, 2023 - Review Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions. Citation Text: Ryan AN, Robertson KL, Glass BD. Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduct…

Receipt of antibiotics in hospitalized patients and risk for Clostridium difficile infection in subsequent patients who occupy the same bed. | PSNet

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September 29, 2017 - Study Receipt of antibiotics in hospitalized patients and risk for Clostridium difficile infection in subsequent patients who occupy the same bed. Citation Text: Freedberg DE, Salmasian H, Cohen B, et al. Receipt of Antibiotics in Hospitalized Patients and Risk for Clostridium difficile …

Pharmacist-led admission medication reconciliation before and after the implementation of an electronic medication management system. | PSNet

psnet.ahrq.gov/issue/pharmacist-led-admission-medication-reconciliation-and-after-implementation-electronic

January 15, 2025 - Study Pharmacist-led admission medication reconciliation before and after the implementation of an electronic medication management system. Citation Text: Sardaneh AA, Burke R, Ritchie A, et al. Pharmacist-led admission medication reconciliation before and after the implementation of an …

Uptake of pharmacist recommendations by patients after discharge: implementation study of a patient-centered medicines review service. | PSNet

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December 14, 2016 - Study Uptake of pharmacist recommendations by patients after discharge: implementation study of a patient-centered medicines review service. Citation Text: Basger BJ, Moles RJ, Chen TF. Uptake of pharmacist recommendations by patients after discharge: implementation study of a patient-ce…

Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events in an oncology population. | PSNet

psnet.ahrq.gov/issue/comparison-voluntary-safety-reporting-system-global-trigger-tool-identifying-adverse-events

July 24, 2017 - Study Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events in an oncology population. Citation Text: Samal L, Khasnabish S, Foskett C, et al. Comparison of a voluntary safety reporting system to a global trigger tool for identifying ad…

Reviewing deaths in British and US hospitals: a study of two scales for assessing preventability. | PSNet

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April 03, 2019 - Study Reviewing deaths in British and US hospitals: a study of two scales for assessing preventability. Citation Text: Manaseki-Holland S, Lilford RJ, Bishop JRB, et al. Reviewing deaths in British and US hospitals: a study of two scales for assessing preventability. BMJ Qual Saf. 2017;2…

Potentially inappropriate prescribing in older people with dementia in care homes: a retrospective analysis. | PSNet

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April 20, 2022 - Study Potentially inappropriate prescribing in older people with dementia in care homes: a retrospective analysis. Citation Text: Parsons C, Johnston S, Mathie E, et al. Potentially inappropriate prescribing in older people with dementia in care homes: a retrospective analysis. Drugs Ag…

Society for Maternal-Fetal Medicine Special Statement: curriculum outline on patient safety and quality for maternal-fetal medicine fellows. | PSNet

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September 22, 2021 - Organizational Policy/Guidelines Society for Maternal-Fetal Medicine Special Statement: curriculum outline on patient safety and quality for maternal-fetal medicine fellows. Citation Text: Society for Maternal-Fetal Medicine Special Statement: curriculum outline on patient safety and qua…

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