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psnet.ahrq.gov/issue/diagnostic-excellence-us-rural-healthcare-call-action
December 22, 2018 - Book/Report
Diagnostic Excellence in U.S. Rural Healthcare: A Call to Action.
Citation Text:
Ali KJ, Galvez NJ, Craig S, et al. Diagnostic Excellence In U.s. Rural Healthcare: A Call To Action. Rockville, MD: Agency for Healthcare Research and Quality; September 2024. AHRQ Publication No…
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psnet.ahrq.gov/issue/diagnostic-error-critically-ill-defining-problem-and-exploring-next-steps-advance-intensive
January 24, 2024 - Commentary
Diagnostic error in the critically ill: defining the problem and exploring next steps to advance intensive care unit safety.
Citation Text:
Bergl PA, Nanchal RS, Singh H. Diagnostic Error in the Critically III: Defining the Problem and Exploring Next Steps to Advance Intensive…
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psnet.ahrq.gov/issue/identification-and-characterization-adverse-drug-events-primary-care
July 16, 2015 - Study
Identification and characterization of adverse drug events in primary care.
Citation Text:
Trinkley KE, Weed HG, Beatty SJ, et al. Identification and Characterization of Adverse Drug Events in Primary Care. Am J Med Qual. 2017;32(5):518-525. doi:10.1177/1062860616665695.
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psnet.ahrq.gov/issue/understanding-patient-safety-performance-and-educational-needs-using-safety-ii-approach
September 28, 2016 - Commentary
Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems.
Citation Text:
McNab D, Bowie P, Morrison J, et al. Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex syst…
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psnet.ahrq.gov/issue/electronic-results-management-pediatric-ambulatory-care-qualitative-assessment
September 26, 2012 - Study
Electronic results management in pediatric ambulatory care: qualitative assessment.
Citation Text:
Ferris T, Johnson SA, Co JPT, et al. Electronic results management in pediatric ambulatory care: qualitative assessment. Pediatrics. 2009;123 Suppl 2:S85-91. doi:10.1542/peds.2008-1…
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psnet.ahrq.gov/issue/review-alternatives-root-cause-analysis-developing-robust-system-incident-report-analysis
November 14, 2018 - Review
Review of alternatives to root cause analysis: developing a robust system for incident report analysis.
Citation Text:
Hagley G, Mills PD, Watts B, et al. Review of alternatives to root cause analysis: developing a robust system for incident report analysis. BMJ Open Qual. 2019;8(…
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psnet.ahrq.gov/issue/adverse-event-screening-tool-based-routinely-collected-hospital-acquired-diagnoses
July 23, 2008 - Study
An adverse event screening tool based on routinely collected hospital-acquired diagnoses.
Citation Text:
Brand CA, Tropea J, Gorelik A, et al. An adverse event screening tool based on routinely collected hospital-acquired diagnoses. Int J Qual Health Care. 2012;24(3):266-78. doi:10…
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psnet.ahrq.gov/issue/workforce-planning-and-safe-workload-sterile-compounding-hospital-pharmacy-services
October 19, 2022 - Study
Workforce planning and safe workload in sterile compounding hospital pharmacy services.
Citation Text:
Chaker A, Omair I, Mohamed WH, et al. Workforce planning and safe workload in sterile compounding hospital pharmacy services. Am J Health Syst Pharm. 2022;79(3):187–192. doi:10.10…
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psnet.ahrq.gov/issue/safety-home-healthcare-sector-development-new-household-safety-checklist
July 29, 2020 - Study
Safety in the home healthcare sector: development of a new household safety checklist.
Citation Text:
Gershon RRM, Dailey M, Magda LA, et al. Safety in the home healthcare sector: development of a new household safety checklist. J Patient Saf. 2012;8(2):51-9. doi:10.1097/PTS.0b0…
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psnet.ahrq.gov/issue/improving-sepsis-care-through-systems-change-impact-medical-emergency-team
December 02, 2009 - Commentary
Improving sepsis care through systems change: the impact of a medical emergency team.
Citation Text:
Sarani B, Brenner SR, Gabel B, et al. Improving sepsis care through systems change: the impact of a medical emergency team. Jt Comm J Qual Patient Saf. 2008;34(3):179-182, 12…
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psnet.ahrq.gov/issue/overnight-and-postcall-errors-medication-orders
May 18, 2022 - Study
Overnight and postcall errors in medication orders.
Citation Text:
Hendey GW, Barth BE, Soliz T. Overnight and postcall errors in medication orders. Acad Emerg Med. 2005;12(7):629-34.
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psnet.ahrq.gov/issue/medication-errors-resulting-computer-entry-nonprescribers
January 02, 2017 - Study
Medication errors resulting from computer entry by nonprescribers.
Citation Text:
Santell JP, Kowiatek JG, Weber RJ, et al. Medication errors resulting from computer entry by nonprescribers. Am J Health Syst Pharm. 2009;66(9):843-53. doi:10.2146/ajhp080208.
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psnet.ahrq.gov/issue/use-patient-pictures-and-verification-screens-reduce-computerized-provider-order-entry-errors
November 16, 2022 - Study
The use of patient pictures and verification screens to reduce computerized provider order entry errors.
Citation Text:
Hyman D, Laire M, Redmond D, et al. The use of patient pictures and verification screens to reduce computerized provider order entry errors. Pediatrics. 2012;130(…
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psnet.ahrq.gov/issue/briefing-and-debriefing-operating-room-using-fighter-pilot-crew-resource-management
May 29, 2024 - Study
Briefing and debriefing in the operating room using fighter pilot crew resource management.
Citation Text:
McGreevy JM, Otten TD. Briefing and debriefing in the operating room using fighter pilot crew resource management. J Am Coll Surg. 2007;205(1):169-76.
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psnet.ahrq.gov/issue/hospital-sequelae-injurious-falls-24-medicalsurgical-units-four-hospitals-united-states
December 12, 2012 - Study
In-hospital sequelae of injurious falls in 24 medical/surgical units in four hospitals in the United States.
Citation Text:
Hill A-M, Jacques A, Chandler M, et al. In-Hospital Sequelae of Injurious Falls in 24 Medical/Surgical Units in Four Hospitals in the United States. Jt Comm J…
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psnet.ahrq.gov/issue/effects-safety-checklists-medicine-systematic-review
December 07, 2011 - Review
The effects of safety checklists in medicine: a systematic review.
Citation Text:
Thomassen Ø, Storesund A, Søfteland E, et al. The effects of safety checklists in medicine: a systematic review. Acta Anaesthesiol Scand. 2014;58(1):5-18. doi:10.1111/aas.12207.
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psnet.ahrq.gov/issue/pilot-study-examining-undesirable-events-among-emergency-department-boarded-patients-awaiting
August 04, 2021 - Study
A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient beds.
Citation Text:
Liu SW, Thomas SH, Gordon JA, et al. A pilot study examining undesirable events among emergency department-boarded patients awaiting inpatient beds. Ann E…
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psnet.ahrq.gov/issue/teaching-medication-reconciliation-through-simulation-patient-safety-initiative-second-year
May 04, 2010 - Commentary
Teaching medication reconciliation through simulation: a patient safety initiative for second year medical students.
Citation Text:
Lindquist LA, Gleason KM, McDaniel MR, et al. Teaching medication reconciliation through simulation: a patient safety initiative for second yea…
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psnet.ahrq.gov/issue/why-it-so-hard-talk-about-overuse-pediatrics-and-why-it-matters
March 04, 2020 - Commentary
Why it is so hard to talk about overuse in pediatrics and why it matters.
Citation Text:
Ralston SL, Schroeder AR. Why It Is So Hard to Talk About Overuse in Pediatrics and Why It Matters. JAMA Pediatr. 2017;171(10):931-932. doi:10.1001/jamapediatrics.2017.2239.
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psnet.ahrq.gov/issue/pediatric-residents-decision-making-around-disclosing-and-reporting-adverse-events-importance
January 25, 2017 - Study
Pediatric residents' decision-making around disclosing and reporting adverse events: the importance of social context.
Citation Text:
Coffey M, Thomson K, Tallett S, et al. Pediatric residents' decision-making around disclosing and reporting adverse events: the importance of social…