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  1. 1,300 days and counting: a risk model approach to preventing retained foreign objects (RFOs). | PSNet

    psnet.ahrq.gov/issue/1300-days-and-counting-risk-model-approach-preventing-retained-foreign-objects-rfos
    April 12, 2019 - Commentary 1,300 days and counting: a risk model approach to preventing retained foreign objects (RFOs). Citation Text: Duggan EG, Fernandez J, Saulan MM, et al. 1,300 Days and Counting: A Risk Model Approach to Preventing Retained Foreign Objects (RFOs). Jt Comm J Qual Patient Saf. 2018…

  2. Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK. | PSNet

    psnet.ahrq.gov/issue/psychometric-properties-hospital-survey-patient-safety-culture-findings-uk
    March 22, 2023 - Study Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK. Citation Text: Waterson P, Griffiths P, Stride C, et al. Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK. Qual Saf Health Care. 2010;19(5…

  3. Speak up! Addressing the paradox plaguing patient-centered care. | PSNet

    psnet.ahrq.gov/issue/speak-addressing-paradox-plaguing-patient-centered-care
    October 17, 2018 - Commentary Speak up! Addressing the paradox plaguing patient-centered care. Citation Text: Mazor KM, Smith KM, Fisher K, et al. Speak Up! Addressing the Paradox Plaguing Patient-Centered Care. Ann Intern Med. 2016;164(9):618-9. doi:10.7326/M15-2416. Copy Citation Format: DO…

  4. 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…

  5. Impact of a pharmacist on medication reconciliation on patient admission to a Veterans Affairs Medical Center. | PSNet

    psnet.ahrq.gov/issue/impact-pharmacist-medication-reconciliation-patient-admission-veterans-affairs-medical-center
    July 22, 2020 - Study Impact of a pharmacist on medication reconciliation on patient admission to a Veterans Affairs Medical Center. Citation Text: Strunk LB, Matson AW, Steinke DT. Impact of a Pharmacist on Medication Reconciliation on Patient Admission to a Veterans Affairs Medical Center. Hosp Pharm.…

  6. Improving medication management for patients: the effect of a pharmacist on post-admission ward rounds. | PSNet

    psnet.ahrq.gov/issue/improving-medication-management-patients-effect-pharmacist-post-admission-ward-rounds
    February 02, 2011 - Study Improving medication management for patients: the effect of a pharmacist on post-admission ward rounds. Citation Text: Fertleman M, Barnett N, Patel T. Improving medication management for patients: the effect of a pharmacist on post-admission ward rounds. Qual Saf Health Care. 20…

  7. 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…

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

    psnet.ahrq.gov/issue/idea-safety-training-improve-critical-thinking-individuals-and-teams
    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…

  9. 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…

  10. 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. …

  11. 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…

  12. 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):…

  13. 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…

  14. 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.…

  15. 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 …

  16. 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…

  17. 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…

  18. 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…

  19. 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…

  20. 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…
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