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9381. No excuses: the reality that demands action. | PSNet
      psnet.ahrq.gov/issue/no-excuses-reality-demands-action
      July 20, 2022 - Meeting/Conference Proceedings No excuses: the reality that demands action. Citation Text: Denham CR, Bagian JP, Daley J, et al. No Excuses: The Reality That Demands Action. doi:10.1097/01.jps.0000183854.29928.4d. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3…

9382. Medication prescribing errors involving the route of administration. | PSNet
      psnet.ahrq.gov/issue/medication-prescribing-errors-involving-route-administration
      January 12, 2011 - Study Medication prescribing errors involving the route of administration. Citation Text: Lesar TS. Medication Prescribing Errors Involving the Route of Administration. Hosp Pharm. 2010;41(11):1053-1066. doi:10.1310/hpj4111-1053. Copy Citation Format: DOI Google Scholar Bib…

9383. Microsoft Word - Hoonakker et al WWCS 2007.doc (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/Hoonakkeretal_WWCS2007.pdf
      June 16, 2021 - Microsoft Word - Hoonakker et al WWCS 2007.doc Proposed theme: 3.2 or 1.4 Prefer to have it as a poster: No Measuring end user satisfaction in CPOE implementation Peter Hoonakker & Pascale Carayon E: phoonakker@cqpi.engr.wisc.edu Center for Quality and Productivity Improvement, University of Wis…

9384. Improving care transitions: optimizing medication reconciliation. | PSNet
      psnet.ahrq.gov/issue/improving-care-transitions-optimizing-medication-reconciliation
      June 17, 2014 - Commentary Improving care transitions: optimizing medication reconciliation. Citation Text: Association AP, Pharmacists AS of H-S, Steeb D, et al. Improving care transitions: optimizing medication reconciliation. J Am Pharm Assoc (2003). 2012;52(4):e43-e52. doi:10.1331/JAPhA.2012.12527…

9385. The emotional fallout from the culture of blame and shame. | PSNet
      psnet.ahrq.gov/issue/emotional-fallout-culture-blame-and-shame
      October 28, 2020 - Commentary The emotional fallout from the culture of blame and shame. Citation Text: Ferguson CC. The emotional fallout from the culture of blame and shame. JAMA Pediatr. 2017;171(12):1141. doi:10.1001/jamapediatrics.2017.2691. Copy Citation Format: DOI Google Scholar PubMe…

9386. 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…

9387. 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…

9388. AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/intro.html
      November 01, 2014 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Introduction This document provides an overview of the components of On-Time Pressure Ulcer Prevention, reports, and implementation materials used in preventing pressure ulcers in nursing homes. On-Time Pressure Ulcer Prevention has be…

9389. ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings. | PSNet
      psnet.ahrq.gov/issue/ismp-list-high-alert-medications-long-term-care-ltc-settings
      December 15, 2021 - Fact Sheet/FAQs ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings. Citation Text: ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings. Horsham, PA: Institute of Safe Medication Practices; 2021 Copy Citation Save Save to your lib…

9390. Nursing home workers warned government about safety violations before COVID-19 outbreaks and deaths. | PSNet
      psnet.ahrq.gov/issue/nursing-home-workers-warned-government-about-safety-violations-covid-19-outbreaks-and-deaths
      September 15, 2021 - Newspaper/Magazine Article Nursing home workers warned government about safety violations before COVID-19 outbreaks and deaths. Citation Text: Nursing home workers warned government about safety violations before COVID-19 outbreaks and deaths. Ellis B, Hicken M. CNN. May 14, 2020. Co…

9391. 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…

9392. Checklist: Creating a Medicine List When Patient Does NOT Bring Medicines (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-checklist-nomeds-final508.pdf
      June 02, 2025 - Checklist: Creating a Medicine List When Patient Does NOT Bring Medicines The Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Checklist: Creating a Medicine List When patient does NOT bring medicines Starting the Process � Use the word “medicine” instead of medication.…

9393. Fixing a broken EHR: HIM working in the spotlight to solve common EHR issues. | PSNet
      psnet.ahrq.gov/issue/fixing-broken-ehr-him-working-spotlight-solve-common-ehr-issues
      March 30, 2016 - Newspaper/Magazine Article Fixing a broken EHR: HIM working in the spotlight to solve common EHR issues. Citation Text: Fixing a broken EHR: HIM working in the spotlight to solve common EHR issues. Butler M. J AHIMA. March 2015;86:18-23. Copy Citation Save Save to…

9394. Families are struggling to use medicines at home — we must truly involve them in their own safety. | PSNet
      psnet.ahrq.gov/issue/families-are-struggling-use-medicines-home-we-must-truly-involve-them-their-own-safety
      February 02, 2022 - Newspaper/Magazine Article Families are struggling to use medicines at home — we must truly involve them in their own safety. Citation Text: Families are struggling to use medicines at home — we must truly involve them in their own safety. Morris S, O’Hara J. Pharmacuetical Journal.…

9395. Simulation-based training for patient safety: 10 principles that matter. | PSNet
      psnet.ahrq.gov/issue/simulation-based-training-patient-safety-10-principles-matter
      January 02, 2017 - Review Simulation-based training for patient safety: 10 principles that matter. Citation Text: Salas E, Wilson KA, Lazzara EH, et al. Simulation-Based Training for Patient Safety. J Patient Saf. 2008;4(1). doi:10.1097/pts.0b013e3181656dd6. Copy Citation Format: DOI Google…

9396. Pandemic imperiled non-English speakers more than others. | PSNet
      psnet.ahrq.gov/issue/pandemic-imperiled-non-english-speakers-more-others
      January 15, 2020 - Newspaper/Magazine Article Pandemic imperiled non-English speakers more than others. Citation Text: Pandemic imperiled non-English speakers more than others. Bebinger M. WBUR and Kaiser Health News. April 27, 2021. Copy Citation Save Save to your library …

9397. Sent home to die. | PSNet
      psnet.ahrq.gov/issue/sent-home-die
      April 22, 2020 - Newspaper/Magazine Article Sent home to die. Citation Text: Waldman A, Kaplan J. Sent home to die. ProPublica. 2020. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation Save S…

9398. Using information from external errors to signal a "clear and present danger." | PSNet
      psnet.ahrq.gov/issue/using-information-external-errors-signal-clear-and-present-danger
      March 14, 2023 - Newspaper/Magazine Article Using information from external errors to signal a "clear and present danger." Citation Text: Using information from external errors to signal a "clear and present danger." ISMP Medication Safety Alert! Acute care edition. February 9, 2017;22:1-5. Copy Citati…

9399. COVID-19 exposes potential gaps in PPE training, effectiveness. | PSNet
      psnet.ahrq.gov/issue/covid-19-exposes-potential-gaps-ppe-training-effectiveness
      May 26, 2021 - Newspaper/Magazine Article COVID-19 exposes potential gaps in PPE training, effectiveness. Citation Text: COVID-19 exposes potential gaps in PPE training, effectiveness. Ault A. Medscape Medical News. April 6, 2020. Copy Citation Save Save to your library …

9400. In U.S. nursing homes, where Covid-19 killed scores, even reports of maggots and rape don’t dock five-star ratings. | PSNet
      psnet.ahrq.gov/issue/us-nursing-homes-where-covid-19-killed-scores-even-reports-maggots-and-rape-dont-dock-five
      December 22, 2021 - Newspaper/Magazine Article In U.S. nursing homes, where Covid-19 killed scores, even reports of maggots and rape don’t dock five-star ratings. Citation Text: In U.S. nursing homes, where Covid-19 killed scores, even reports of maggots and rape don’t dock five-star ratings. Silver-Greenbe…