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  1. Notes on healing after a missed diagnosis. | PSNet

    psnet.ahrq.gov/issue/notes-healing-after-missed-diagnosis
    May 18, 2022 - Commentary Notes on healing after a missed diagnosis. Citation Text: Fleming EA. Notes on healing after a missed diagnosis. JAMA. 2022;328(13):1297-1298. doi:10.1001/jama.2022.15724. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…

  2. Nighttime and weekend medication error rates in an inpatient pediatric population. | PSNet

    psnet.ahrq.gov/issue/nighttime-and-weekend-medication-error-rates-inpatient-pediatric-population
    October 19, 2022 - Study Nighttime and weekend medication error rates in an inpatient pediatric population. Citation Text: Miller AD, Piro CC, Rudisill CN, et al. Nighttime and weekend medication error rates in an inpatient pediatric population. Ann Pharmacother. 2010;44(11):1739-46. doi:10.1345/aph.1P25…

  3. The 'time-out' procedure: an institutional ethnography of how it is conducted in actual clinical practice. | PSNet

    psnet.ahrq.gov/issue/time-out-procedure-institutional-ethnography-how-it-conducted-actual-clinical-practice
    November 06, 2015 - Study The 'time-out' procedure: an institutional ethnography of how it is conducted in actual clinical practice. Citation Text: Braaf S, Manias E, Riley R. The 'time-out' procedure: an institutional ethnography of how it is conducted in actual clinical practice. BMJ Qual Saf. 2013;22(8)…

  4. Pediatric medication administration errors and workflow following implementation of a bar code medication administration system. | PSNet

    psnet.ahrq.gov/issue/pediatric-medication-administration-errors-and-workflow-following-implementation-bar-code
    July 02, 2019 - Study Pediatric medication administration errors and workflow following implementation of a bar code medication administration system. Citation Text: Hardmeier A, Tsourounis C, Moore M, et al. Pediatric medication administration errors and workflow following implementation of a bar code …

  5. Development and validation of a tool to improve paediatric referral/consultation communication. | PSNet

    psnet.ahrq.gov/issue/development-and-validation-tool-improve-paediatric-referralconsultation-communication
    May 25, 2011 - Study Development and validation of a tool to improve paediatric referral/consultation communication. Citation Text: Stille CJ, Mazor KM, Meterko V, et al. Development and validation of a tool to improve paediatric referral/consultation communication. BMJ Qual Saf. 2011;20(8):692-7. do…

  6. Medical error reduction and tort reform through private contractually-based quality medicine societies. | PSNet

    psnet.ahrq.gov/issue/medical-error-reduction-and-tort-reform-through-private-contractually-based-quality-medicine
    October 13, 2010 - Commentary Medical error reduction and tort reform through private contractually-based quality medicine societies. Citation Text: MacCourt D, Bernstein J. Medical error reduction and tort reform through private, contractually-based quality medicine societies. Am J Law Med. 2009;35(4):5…

  7. Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R18). | PSNet

    psnet.ahrq.gov/issue/making-health-care-safer-ambulatory-care-settings-and-long-term-care-facilities-r18
    May 30, 2018 - Grant Announcement Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R18). Citation Text: Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R18). Rockville, MD: Agency for Healthcare Research and Quality; April 10, 2018.…

  8. Beyond "see one, do one, teach one": toward a different training paradigm. | PSNet

    psnet.ahrq.gov/issue/beyond-see-one-do-one-teach-one-toward-different-training-paradigm
    March 01, 2011 - Commentary Beyond "see one, do one, teach one": toward a different training paradigm. Citation Text: Rodriguez-Paz JM, Kennedy M, Salas E, et al. Beyond "see one, do one, teach one": toward a different training paradigm. Qual Saf Health Care. 2009;18(1):63-8. doi:10.1136/qshc.2007.02…

  9. Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. | PSNet

    psnet.ahrq.gov/issue/towards-safer-better-healthcare-harnessing-natural-properties-complex-sociotechnical-systems
    April 08, 2011 - Commentary Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. Citation Text: Braithwaite J, Runciman WB, Merry AF. Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. Qual Saf Health …

  10. e-Prescribing: characterisation of patient safety hazards in community pharmacies using a sociotechnical systems approach. | PSNet

    psnet.ahrq.gov/issue/e-prescribing-characterisation-patient-safety-hazards-community-pharmacies-using
    January 07, 2015 - Study e-Prescribing: characterisation of patient safety hazards in community pharmacies using a sociotechnical systems approach. Citation Text: Odukoya OK, Chui MA. e-Prescribing: characterisation of patient safety hazards in community pharmacies using a sociotechnical systems approac…

  11. Reducing diagnostic error through medical home-based primary care reform. | PSNet

    psnet.ahrq.gov/issue/reducing-diagnostic-error-through-medical-home-based-primary-care-reform
    July 15, 2015 - Commentary Reducing diagnostic error through medical home-based primary care reform. Citation Text: Singh H, Graber ML. Reducing diagnostic error through medical home-based primary care reform. JAMA. 2010;304(4):463-4. doi:10.1001/jama.2010.1035. Copy Citation Format: DOI G…

  12. Patient handoffs: is cross cover or night shift better? | PSNet

    psnet.ahrq.gov/issue/patient-handoffs-cross-cover-or-night-shift-better
    December 07, 2009 - Study Patient handoffs: is cross cover or night shift better? Citation Text: Higgins A, Brannen ML, Heiman HL, et al. Patient Handoffs: Is Cross Cover or Night Shift Better? J Patient Saf. 2017;13(2):88-92. doi:10.1097/PTS.0000000000000126. Copy Citation Format: DOI Google …

  13. Deploying and measuring a risk and patient safety program. | PSNet

    psnet.ahrq.gov/issue/deploying-and-measuring-risk-and-patient-safety-program
    January 19, 2022 - Commentary Deploying and measuring a risk and patient safety program. Citation Text: Orel H, McGroarty M, Marchegiani H. Deploying and measuring a risk and patient safety program. J Healthc Risk Manag. 2017;36(3):26-33. doi:10.1002/jhrm.21266. Copy Citation Format: DOI Goog…

  14. Mandatory pharmacy residencies: one way to reduce medication errors. | PSNet

    psnet.ahrq.gov/issue/mandatory-pharmacy-residencies-one-way-reduce-medication-errors
    July 23, 2008 - Commentary Mandatory pharmacy residencies: one way to reduce medication errors. Citation Text: Ibrahim RB, Bahgat-Ibrahim L, Reeves D. Mandatory pharmacy residencies: One way to reduce medication errors. Am J Health Syst Pharm. 2010;67(6):477-81. doi:10.2146/ajhp090138. Copy Citation …

  15. Incident reporting in one UK accident and emergency department. | PSNet

    psnet.ahrq.gov/issue/incident-reporting-one-uk-accident-and-emergency-department
    December 12, 2012 - Study Incident reporting in one UK accident and emergency department. Citation Text: Tighe CM, Woloshynowych M, Brown R, et al. Incident reporting in one UK accident and emergency department. Accid Emerg Nurs. 2006;14(1):27-37. Copy Citation Format: Google Scholar PubMed …

  16. Database construction for improving patient safety by examining pathology errors.   | PSNet

    psnet.ahrq.gov/issue/database-construction-improving-patient-safety-examining-pathology-errors
    December 22, 2008 - Commentary Database construction for improving patient safety by examining pathology errors.   Citation Text: Grzybicki DM, Turcsany B, Becich MJ, et al. Database Construction for Improving Patient Safety by Examining Pathology Errors. Am J Clin Pathol. 2008;124(4). doi:10.1309/xn25jg7…

  17. Imitating incidents: how simulation can improve safety investigation and learning from adverse events. | PSNet

    psnet.ahrq.gov/issue/imitating-incidents-how-simulation-can-improve-safety-investigation-and-learning-adverse
    February 28, 2024 - Commentary Imitating incidents: how simulation can improve safety investigation and learning from adverse events. Citation Text: Macrae C. Imitating Incidents: How Simulation Can Improve Safety Investigation and Learning From Adverse Events. Simul Healthc. 2018;13(4):227-232. doi:10.1097…

  18. Artificial intelligence systems for complex decision-making in acute care medicine: a review. | PSNet

    psnet.ahrq.gov/issue/artificial-intelligence-systems-complex-decision-making-acute-care-medicine-review
    March 16, 2011 - Review Emerging Classic Artificial intelligence systems for complex decision-making in acute care medicine: a review. Citation Text: Lynn LA. Artificial intelligence systems for complex decision-making in acute care medicine: a review. Patient Saf Surg. 2019;13:…

  19. Implementing patient safety initiatives in rural hospitals. | PSNet

    psnet.ahrq.gov/issue/implementing-patient-safety-initiatives-rural-hospitals
    September 27, 2010 - Commentary Implementing patient safety initiatives in rural hospitals. Citation Text: Klingner J, Moscovice I, Tupper JB, et al. Implementing Patient Safety Initiatives in Rural Hospitals. J Rural Health. 2009;25(4):352-357. doi:10.1111/j.1748-0361.2009.00243.x. Copy Citation For…

  20. Variation in medication information for elderly patients during initial interventions by emergency department physicians. | PSNet

    psnet.ahrq.gov/issue/variation-medication-information-elderly-patients-during-initial-interventions-emergency
    October 20, 2021 - Study Variation in medication information for elderly patients during initial interventions by emergency department physicians. Citation Text: Cohen V, Jellinek SP, Likourezos A, et al. Variation in medication information for elderly patients during initial interventions by emergency d…
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