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psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
March 01, 2014 - How Does Infection Prevention Fit Into a Safety Program?
Susan S. Huang, MD, MPH | March 1, 2014
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Huang SS. How Does Infection Prevention Fit Into a Safety Program?. PSNet [interne…
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psnet.ahrq.gov/issue/health-care-worker-fatigue-and-patient-safety
December 23, 2016 - Sentinel Event Alerts
Health care worker fatigue and patient safety.
Citation Text:
Health care worker fatigue and patient safety. Sentinel Event Alert. December 14, 2011;(48):1-4. (addendum May 14, 2018).
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psnet.ahrq.gov/issue/using-six-sigma-reduce-medication-errors-home-delivery-pharmacy-service
November 18, 2015 - Study
Using Six Sigma to reduce medication errors in a home-delivery pharmacy service.
Citation Text:
Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24.
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psnet.ahrq.gov/issue/failure-medication-delivery-system-how-disclosure-and-systems-investigation-improve-patient
April 03, 2005 - Commentary
A failure in the medication delivery system-how disclosure and systems investigation improve patient safety.
Citation Text:
Lucas SR, Pollak E, Makowski C. A failure in the medication delivery system—how disclosure and systems investigation improve patient safety. J Healthc Ri…
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psnet.ahrq.gov/issue/perspective-culture-respect-part-1-and-part-2
October 04, 2006 - Commentary
Perspective: a culture of respect—part 1 and part 2.
Citation Text:
Perspective: a culture of respect—part 1 and part 2. Leape LL, Shore MF, Dienstag JL, et al. Acad Med. 2012;87(7):845-858.
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psnet.ahrq.gov/node/33576/psn-pdf
December 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient
Surgery
December 15, 2024
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editoria…
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psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - Zero Harm: How to Achieve Patient and Workforce Safety in Healthcare articulates the importance of establishing
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psnet.ahrq.gov/issue/safe-practice-recommendations-use-copy-forward-nursing-flow-sheets-hospital-settings
May 18, 2022 - Study
Safe practice recommendations for the use of copy-forward with nursing flow sheets in hospital settings.
Citation Text:
Patterson ES, Sillars DM, Staggers N, et al. Safe Practice Recommendations for the Use of Copy-Forward with Nursing Flow Sheets in Hospital Settings. Jt Comm J Qu…
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psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - Even just for this first step of establishing the chronology of events, you need to be able to talk to
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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - Aviation has spent decades establishing a just culture of safety in which there are careful agreements
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psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
September 01, 2012 - the Washington state patient safety act requiring hospital staffing plans for nursing services and establishing
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psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
December 22, 2018 - Don't Use That Port: Insert a PICC
Citation Text:
Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/issue/patient-safety-goals-proposed-federal-health-information-technology-safety-center
November 30, 2011 - Commentary
Classic
Patient safety goals for the proposed Federal Health Information Technology Safety Center.
Citation Text:
Sittig DF, Classen D, Singh H. Patient safety goals for the proposed Federal Health Information Technology Safety Center. J Am Med Inform…
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psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2016-user-comparative-database-report
November 30, 2016 - Book/Report
Hospital Survey on Patient Safety Culture: 2016 User Comparative Database Report.
Citation Text:
Hospital Survey on Patient Safety Culture: 2016 User Comparative Database Report. Famolaro T, Yount ND, Burns W, Flashner E, Liu H, Sorra J. Rockville, MD: Agency for Healthcare …
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psnet.ahrq.gov/issue/disclosing-and-reporting-practice-errors-nurses-residential-long-term-care-settings
April 02, 2015 - Review
Disclosing and reporting practice errors by nurses in residential long-term care settings: a systematic review.
Citation Text:
Vaismoradi M, Vizcaya-Moreno F, Jordan S, et al. Disclosing and reporting practice errors by nurses in residential long-term care settings: a systematic r…
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psnet.ahrq.gov/issue/radiologic-safety-events-within-pediatric-emergency-medicine-network
August 01, 2018 - Study
Radiologic safety events within a pediatric emergency medicine network.
Citation Text:
Blumberg SM, Mahajan P, OʼConnell KJ, et al. Radiologic Safety Events Within a Pediatric Emergency Medicine Network. Pediatr Emerg Care. 2017;33(2):92-96. doi:10.1097/PEC.0000000000000684.
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psnet.ahrq.gov/issue/programmable-infusion-pumps-icus-analysis-corresponding-adverse-drug-events
January 16, 2008 - Study
Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events.
Citation Text:
Nuckols TK, Bower AG, Paddock SM, et al. Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events. J Gen Intern Med. 2008;23 Suppl 1:41-5. doi:10.100…
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psnet.ahrq.gov/issue/surgeon-information-transfer-and-communication-factors-affecting-quality-and-efficiency
December 21, 2014 - Study
Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care.
Citation Text:
Williams RG, Silverman R, Schwind C, et al. Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care. Ann S…
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psnet.ahrq.gov/issue/psychological-safety-new-acgme-requirement-comprehensive-all-one-guide-radiology-residency
April 24, 2018 - Review
Psychological safety as a new ACGME requirement: a comprehensive all-in-one guide to radiology residency programs.
Citation Text:
Mohamed I, Hom GL, Jiang S, et al. Psychological safety as a new ACGME requirement: a comprehensive all-in-one guide to radiology residency programs. A…
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psnet.ahrq.gov/issue/role-theory-research-develop-and-evaluate-implementation-patient-safety-practices
September 20, 2011 - Commentary
The role of theory in research to develop and evaluate the implementation of patient safety practices.
Citation Text:
Foy R, Ovretveit J, Shekelle PG, et al. The role of theory in research to develop and evaluate the implementation of patient safety practices. BMJ Qual Saf. …