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Variability in the concentrations of intravenous drug infusions prepared in a critical care unit. | PSNet

psnet.ahrq.gov/issue/variability-concentrations-intravenous-drug-infusions-prepared-critical-care-unit

March 02, 2011 - Study Variability in the concentrations of intravenous drug infusions prepared in a critical care unit. Citation Text: Wheeler DW, Degnan BA, Sehmi JS, et al. Variability in the concentrations of intravenous drug infusions prepared in a critical care unit. Intensive Care Med. 2008;34(8…

Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council. | PSNet

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December 27, 2014 - Commentary Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council. Citation Text: Fleischut PM, Evans AS, Nugent WC, et al. Ten years after the IOM report: Engaging residents in quality and patient safety by creating a …

Engineering a safe landing: engaging medical practitioners in a systems approach to patient safety. | PSNet

psnet.ahrq.gov/issue/engineering-safe-landing-engaging-medical-practitioners-systems-approach-patient-safety

July 23, 2008 - Study Engineering a safe landing: engaging medical practitioners in a systems approach to patient safety. Citation Text: Brand C, Ibrahim JE, Bain C, et al. Engineering a safe landing: engaging medical practitioners in a systems approach to patient safety. Intern Med J. 2007;37(5):295-…

Informing the design of a new pragmatic registry to stimulate near miss reporting in ambulatory care. | PSNet

psnet.ahrq.gov/issue/informing-design-new-pragmatic-registry-stimulate-near-miss-reporting-ambulatory-care

January 12, 2011 - Review Informing the design of a new pragmatic registry to stimulate near miss reporting in ambulatory care. Citation Text: Pfoh ER, Engineer L, Singh H, et al. Informing the Design of a New Pragmatic Registry to Stimulate Near Miss Reporting in Ambulatory Care. J Patient Saf. 2021;17(3)…

Lost in translation? Addressing barriers in the application of industrial process improvement methodologies to health care. | PSNet

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May 11, 2019 - Commentary Lost in translation? Addressing barriers in the application of industrial process improvement methodologies to health care. Citation Text: Gray D, Johnson KD, Watts B. Lost In Translation? Addressing Barriers in the Application of Industrial Process Improvement Methodologies t…

Latent risk assessment tool for health care leaders. | PSNet

psnet.ahrq.gov/issue/latent-risk-assessment-tool-health-care-leaders

September 05, 2018 - Commentary Latent risk assessment tool for health care leaders. Citation Text: Paine LA, Holzmueller CG, Elliott R, et al. Latent risk assessment tool for health care leaders. J Healthc Risk Manag. 2018;38(2):36-46. doi:10.1002/jhrm.21316. Copy Citation Format: DOI Google S…

Ten years of incident reports on in-hospital cardiac arrest - Are they useful for improvements? | PSNet

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January 26, 2022 - Study Ten years of incident reports on in-hospital cardiac arrest - Are they useful for improvements? Citation Text: Djärv T. Ten years of incident reports on in-hospital cardiac arrest – Are they useful for improvements? Resusc Plus. 2023;17:100525. doi:10.1016/j.resplu.2023.100525. C…

Bar code medication administration technology: characterization of high-alert medication triggers and clinician workarounds. | PSNet

psnet.ahrq.gov/issue/bar-code-medication-administration-technology-characterization-high-alert-medication-triggers

April 24, 2018 - Study Bar code medication administration technology: characterization of high-alert medication triggers and clinician workarounds. Citation Text: Miller DF, Fortier CR, Garrison KL. Bar Code Medication Administration Technology: Characterization of High-Alert Medication Triggers and Cl…

Safety culture and care: a program to prevent surgical errors. | PSNet

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March 25, 2020 - Commentary Safety culture and care: a program to prevent surgical errors. Citation Text: Hemingway MW, O'Malley C, Silvestri S. Safety culture and care: a program to prevent surgical errors. AORN J. 2015;101(4):404-12; quiz 413-5. doi:10.1016/j.aorn.2015.01.002. Copy Citation Forma…

Structuring feedback and debriefing to achieve mastery learning goals. | PSNet

psnet.ahrq.gov/issue/structuring-feedback-and-debriefing-achieve-mastery-learning-goals

September 02, 2020 - Study Structuring feedback and debriefing to achieve mastery learning goals. Citation Text: Eppich W, Hunt EA, Duval-Arnould JM, et al. Structuring feedback and debriefing to achieve mastery learning goals. Acad Med. 2015;90(11):1501-8. doi:10.1097/ACM.0000000000000934. Copy Citation …

Reducing medical error in the Military Health System: how can team training help? | PSNet

psnet.ahrq.gov/issue/reducing-medical-error-military-health-system-how-can-team-training-help

March 29, 2007 - Commentary Reducing medical error in the Military Health System: how can team training help? Citation Text: Alonso A, Baker DP, Holtzman A, et al. Reducing medical error in the Military Health System: How can team training help? Human Resource Management Review. 2006;16(3). doi:10.101…

The impact of major intraoperative adverse events on hospital readmissions. | PSNet

psnet.ahrq.gov/issue/impact-major-intraoperative-adverse-events-hospital-readmissions

July 01, 2017 - Study The impact of major intraoperative adverse events on hospital readmissions. Citation Text: Nandan AR, Bohnen JD, Chang DC, et al. The impact of major intraoperative adverse events on hospital readmissions. Am J Surg. 2017;213(1):10-17. doi:10.1016/j.amjsurg.2016.03.018. Copy Cita…

From battles to burnout: investigating the role of interphysician conflict in physician burnout. | PSNet

psnet.ahrq.gov/issue/battles-burnout-investigating-role-interphysician-conflict-physician-burnout

August 23, 2023 - Study From battles to burnout: investigating the role of interphysician conflict in physician burnout. Citation Text: Amick AE, Schrepel C, Bann M, et al. From battles to burnout: investigating the role of interphysician conflict in physician burnout. Acad Med. 2023;98(9):1076-1082. doi:…

The effect of medication reconciliation in elderly patients at hospital discharge. | PSNet

psnet.ahrq.gov/issue/effect-medication-reconciliation-elderly-patients-hospital-discharge

February 04, 2009 - Study The effect of medication reconciliation in elderly patients at hospital discharge. Citation Text: Midlöv P, Bahrani L, Seyfali M, et al. The effect of medication reconciliation in elderly patients at hospital discharge. Int J Clin Pharm. 2012;34(1):113-9. doi:10.1007/s11096-011-9…

ASHP guidelines on perioperative pharmacy services. | PSNet

psnet.ahrq.gov/issue/ashp-guidelines-perioperative-pharmacy-services

December 21, 2014 - Review ASHP guidelines on perioperative pharmacy services. Citation Text: Bickham P, Golembiewski J, Meyer T, et al. ASHP guidelines on perioperative pharmacy services. Am J Health Syst Pharm. 2019;76(12):903-820. doi:10.1093/ajhp/zxz073. Copy Citation Format: DOI Google Sc…

Post-event debriefings during neonatal care: why are we not doing them, and how can we start? | PSNet

psnet.ahrq.gov/issue/post-event-debriefings-during-neonatal-care-why-are-we-not-doing-them-and-how-can-we-start

January 15, 2014 - Commentary Post-event debriefings during neonatal care: why are we not doing them, and how can we start? Citation Text: Sawyer T, Loren D, Halamek LP. Post-event debriefings during neonatal care: why are we not doing them, and how can we start? J Perinatol. 2016;36(6):415-9. doi:10.1038/…

The surgical safety checklist and teamwork coaching tools: a study of inter-rater reliability. | PSNet

psnet.ahrq.gov/issue/surgical-safety-checklist-and-teamwork-coaching-tools-study-inter-rater-reliability

May 11, 2016 - Study The surgical safety checklist and teamwork coaching tools: a study of inter-rater reliability. Citation Text: Huang LC, Conley D, Lipsitz S, et al. The Surgical Safety Checklist and Teamwork Coaching Tools: a study of inter-rater reliability. BMJ Qual Saf. 2014;23(8):639-50. doi:10…

Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards. | PSNet

psnet.ahrq.gov/issue/track-trigger-and-teamwork-communication-deterioration-acute-medical-and-surgical-wards

August 06, 2014 - Study Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards. Citation Text: Donohue LA, Endacott R. Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards. Intensive Crit Care Nurs. 2010;26(1):10-7. doi:…

Using medicolegal data to support safe medical care: a contributing factor coding framework. | PSNet

psnet.ahrq.gov/issue/using-medicolegal-data-support-safe-medical-care-contributing-factor-coding-framework

April 03, 2024 - Commentary Using medicolegal data to support safe medical care: a contributing factor coding framework. Citation Text: McCleery A, Devenny K, Ogilby C, et al. Using medicolegal data to support safe medical care: A contributing factor coding framework. J Healthc Risk Manag. 2019;38(4):11-…

Using failure mode and effects analysis to plan implementation of smart i.v. pump technology. | PSNet

psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-plan-implementation-smart-iv-pump-technology

July 14, 2010 - Study Using failure mode and effects analysis to plan implementation of smart i.v. pump technology. Citation Text: Wetterneck TB, Skibinski K, Roberts TL, et al. Using failure mode and effects analysis to plan implementation of smart i.v. pump technology. Am J Health Syst Pharm. 2006;6…

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