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Fentanyl transdermal system (marketed as Duragesic) information. | PSNet

psnet.ahrq.gov/issue/safety-warnings-regarding-use-fentanyl-transdermal-skin-patches

August 12, 2015 - Government Resource Fentanyl transdermal system (marketed as Duragesic) information. Citation Text: Fentanyl transdermal system (marketed as Duragesic) information. US Food and Drug Administration. MedWatch. July 10, 2015. Copy Citation Save Save to your library…

An IDEA: safety training to improve critical thinking by individuals and teams. | PSNet

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May 25, 2016 - Commentary An IDEA: safety training to improve critical thinking by individuals and teams. Citation Text: Browne AM, Deutsch ES, Corwin K, et al. An IDEA: Safety Training to Improve Critical Thinking by Individuals and Teams. Am J Med Qual. 2019;34(6):569-576. doi:10.1177/106286061882068…

As she lay dying: how I fought to stop medical errors from killing my mom. | PSNet

psnet.ahrq.gov/issue/she-lay-dying-how-i-fought-stop-medical-errors-killing-my-mom

December 19, 2012 - Commentary As she lay dying: how I fought to stop medical errors from killing my mom. Citation Text: Welch JR. As she lay dying: how I fought to stop medical errors from killing my mom. Health Aff (Millwood). 2012;31(12):2817-2820. doi:10.1377/hlthaff.2012.0833. Copy Citation For…

Revisiting duty-hour limits — IOM recommendations for patient safety and resident education. | PSNet

psnet.ahrq.gov/issue/revisiting-duty-hour-limits-iom-recommendations-patient-safety-and-resident-education

February 17, 2011 - Commentary Revisiting duty-hour limits — IOM recommendations for patient safety and resident education. Citation Text: Iglehart JK. Revisiting duty-hour limits--IOM recommendations for patient safety and resident education. N Engl J Med. 2008;359(25):2633-5. doi:10.1056/NEJMp0808736. …

Provider and pharmacist responses to warfarin drug–drug interaction alerts: a study of healthcare downstream of CPOE alerts. | PSNet

psnet.ahrq.gov/issue/provider-and-pharmacist-responses-warfarin-drug-drug-interaction-alerts-study-healthcare

July 29, 2020 - Study Provider and pharmacist responses to warfarin drug–drug interaction alerts: a study of healthcare downstream of CPOE alerts. Citation Text: Miller AM, Boro MS, Korman NE, et al. Provider and pharmacist responses to warfarin drug-drug interaction alerts: a study of healthcare downst…

A framework for patient safety: a defense nuclear industry-based high-reliability model. | PSNet

psnet.ahrq.gov/issue/framework-patient-safety-defense-nuclear-industry-based-high-reliability-model

June 14, 2017 - Commentary A framework for patient safety: a defense nuclear industry-based high-reliability model. Citation Text: Birnbach DJ, Rosen LF, Williams L, et al. A framework for patient safety: a defense nuclear industry--based high-reliability model. Jt Comm J Qual Patient Saf. 2013;39(5):…

Communicating uncertainty: a narrative review and framework for future research. | PSNet

psnet.ahrq.gov/issue/communicating-uncertainty-narrative-review-and-framework-future-research

February 24, 2021 - Review Communicating uncertainty: a narrative review and framework for future research. Citation Text: Simpkin AL, Armstrong KA. Communicating uncertainty: a narrative review and framework for future research. J Gen Intern Med. 2019;34(11):2586-2591. doi:10.1007/s11606-019-04860-8. Cop…

Barcode medication administration software technology use in the emergency department and medication error rates. | PSNet

psnet.ahrq.gov/issue/barcode-medication-administration-software-technology-use-emergency-department-and-medication

November 04, 2015 - Study Barcode medication administration software technology use in the emergency department and medication error rates. Citation Text: Gauthier-Wetzel HE. Barcode medication administration software technology use in the emergency department and medication error rates. Comput Inform Nurs.…

Effectiveness of facilitated introduction of a standard operating procedure into routine processes in the operating theatre: a controlled interrupted time series. | PSNet

psnet.ahrq.gov/issue/effectiveness-facilitated-introduction-standard-operating-procedure-routine-processes

February 04, 2015 - Study Effectiveness of facilitated introduction of a standard operating procedure into routine processes in the operating theatre: a controlled interrupted time series. Citation Text: Morgan L, New S, Robertson ER, et al. Effectiveness of facilitated introduction of a standard operating …

Health services under pressure: a scoping review and development of a taxonomy of adaptive strategies. | PSNet

psnet.ahrq.gov/issue/health-services-under-pressure-scoping-review-and-development-taxonomy-adaptive-strategies

January 22, 2020 - Commentary Health services under pressure: a scoping review and development of a taxonomy of adaptive strategies. Citation Text: Page B, Irving D, Amalberti R, et al. Health services under pressure: a scoping review and development of a taxonomy of adaptive strategies. BMJ Qual Saf. 2023…

Teamwork and team performance in multidisciplinary cancer teams: development and evaluation of an observational assessment tool. | PSNet

psnet.ahrq.gov/issue/teamwork-and-team-performance-multidisciplinary-cancer-teams-development-and-evaluation

August 11, 2010 - Study Teamwork and team performance in multidisciplinary cancer teams: development and evaluation of an observational assessment tool. Citation Text: Lamb BW, Vincent CA, Green JSA, et al. Teamwork and team performance in multidisciplinary cancer teams: development and evaluation of an…

Misuse of pediatric medications and parent–physician communication: an interactive voice response intervention. | PSNet

psnet.ahrq.gov/issue/misuse-pediatric-medications-and-parent-physician-communication-interactive-voice-response

May 27, 2011 - Study Misuse of pediatric medications and parent–physician communication: an interactive voice response intervention. Citation Text: Walsh KE, Bacic J, Phillips BD, et al. Misuse of Pediatric Medications and Parent-Physician Communication: An Interactive Voice Response Intervention. J Pa…

Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine. | PSNet

psnet.ahrq.gov/issue/epidural-pump-programming-error-leading-inadvertent-10-fold-dosing-error-during-epidural

May 13, 2009 - Commentary Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine. Citation Text: Thyen AB, McAllister RK, Councilman LM. Epidural Pump Programming Error Leading to Inadvertent 10-Fold Dosing Error During Epidural La…

A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions. | PSNet

psnet.ahrq.gov/issue/prospective-hazard-and-improvement-analytic-approach-predicting-effectiveness-medication

December 04, 2013 - Study A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions. Citation Text: Karnon J, McIntosh A, Dean JE, et al. A prospective hazard and improvement analytic approach to predicting the effectiveness of medication erro…

The "physician-led chart audit": engaging providers in fortifying a culture of safety. | PSNet

psnet.ahrq.gov/issue/physician-led-chart-audit-engaging-providers-fortifying-culture-safety

November 20, 2013 - Study The "physician-led chart audit": engaging providers in fortifying a culture of safety. Citation Text: Gitkind MJ, Perla RJ, Manno M, et al. The "physician-led chart audit: " engaging providers in fortifying a culture of safety. J Patient Saf. 2014;10(1):72-9. doi:10.1097/PTS.0000…

Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit. | PSNet

psnet.ahrq.gov/issue/effect-lean-intervention-improve-safety-processes-and-outcomes-surgical-emergency-unit

January 04, 2010 - Study Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit. Citation Text: McCulloch P, Kreckler S, New S, et al. Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit. BMJ. 2010;341:c5469.…

Safer Delivery of Surgical Services: a Programme of Controlled Before-and-after Intervention Studies with Pre-planned Pooled Data Analysis. | PSNet

psnet.ahrq.gov/issue/safer-delivery-surgical-services-programme-controlled-and-after-intervention-studies-pre

October 12, 2016 - Book/Report Safer Delivery of Surgical Services: a Programme of Controlled Before-and-after Intervention Studies with Pre-planned Pooled Data Analysis. Citation Text: Safer Delivery of Surgical Services: a Programme of Controlled Before-and-after Intervention Studies with Pre-planned Poo…

Surgical never events and contributing human factors. | PSNet

psnet.ahrq.gov/issue/surgical-never-events-and-contributing-human-factors

August 20, 2018 - Study Classic Surgical never events and contributing human factors. Citation Text: Thiels CA, Lal TM, Nienow JM, et al. Surgical never events and contributing human factors. Surgery. 2015;158(2):515-21. doi:10.1016/j.surg.2015.03.053. Copy Citation Format:…

Doctors' experiences of adverse events in secondary care: the professional and personal impact. | PSNet

psnet.ahrq.gov/issue/doctors-experiences-adverse-events-secondary-care-professional-and-personal-impact

April 10, 2019 - Study Doctors' experiences of adverse events in secondary care: the professional and personal impact. Citation Text: Harrison R, Lawton R, Stewart K. Doctors' experiences of adverse events in secondary care: the professional and personal impact. Clin Med (Lond). 2014;14(6):585-90. doi:10…

The effect of the fit between organizational culture and structure on medication errors in medical group practices. | PSNet

psnet.ahrq.gov/issue/effect-fit-between-organizational-culture-and-structure-medication-errors-medical-group

June 30, 2009 - Study The effect of the fit between organizational culture and structure on medication errors in medical group practices. Citation Text: Kaissi A, Kralewski J, Dowd B, et al. The effect of the fit between organizational culture and structure on medication errors in medical group practi…

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