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Cost implications of actual and potential adverse events prevented by interventions of a critical care pharmacist. | PSNet

psnet.ahrq.gov/issue/cost-implications-actual-and-potential-adverse-events-prevented-interventions-critical-care

June 28, 2010 - Study Cost implications of actual and potential adverse events prevented by interventions of a critical care pharmacist. Citation Text: Kopp BJ, Mrsan M, Erstad BL, et al. Cost implications of and potential adverse events prevented by interventions of a critical care pharmacist. Am J H…

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…

Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture. | PSNet

psnet.ahrq.gov/issue/association-between-implementing-comprehensive-learning-collaborative-strategies-statewide

September 02, 2020 - Study Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture. Citation Text: Yuce TK, Yang AD, Johnson JK, et al. Association between implementing comprehensive learning collaborative strategies…

Using Telehealth to Improve Quality and Safety: Findings from the AHRQ Portfolio. | PSNet

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May 07, 2014 - Book/Report Using Telehealth to Improve Quality and Safety: Findings from the AHRQ Portfolio. Citation Text: Using Telehealth to Improve Quality and Safety: Findings from the AHRQ Portfolio. Dixon BE, Hook JM, McGowan JJ, for AHRQ National Resource Center for Health IT. Rockville, MD: Ag…

The flaw of medicine: addressing racial and gender disparities in critical care. | PSNet

psnet.ahrq.gov/issue/flaw-medicine-addressing-racial-and-gender-disparities-critical-care

June 16, 2010 - Commentary The flaw of medicine: addressing racial and gender disparities in critical care. Citation Text: Hilton EJ, Goff KL, Sreedharan R, et al. The flaw of medicine: addressing racial and gender disparities in critical care. Anesthesiol Clin. 2020;38(2):357-368. doi:10.1016/j.anclin.…

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

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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. …

VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events. | PSNet

psnet.ahrq.gov/issue/va-health-care-improvements-needed-processes-used-address-providers-actions-contribute

October 12, 2022 - Book/Report VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events. Citation Text: VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events. Draper D. Washington,…

Journey to no preventable risk: The Baylor Health Care System patient safety experience. | PSNet

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November 23, 2014 - Commentary Journey to no preventable risk: The Baylor Health Care System patient safety experience. Citation Text: Kennerly DA, Richter KM, Good V, et al. Journey to no preventable risk: the Baylor Health Care System patient safety experience. Am J Med Qual. 2011;26(1):43-52. doi:10.11…

Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties. | PSNet

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January 14, 2009 - Book/Report Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties. Citation Text: Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties. Levinson DR. Washington, DC: US Departmen…

The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technologies. | PSNet

psnet.ahrq.gov/issue/confused-and-bewildered-hospital-adverse-event-discovery-pay-performance-and-big-data-tools

September 23, 2020 - Commentary The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technologies. Citation Text: Furrow BR. The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technolog…

Transferring aviation practices into clinical medicine for the promotion of high reliability. | PSNet

psnet.ahrq.gov/issue/transferring-aviation-practices-clinical-medicine-promotion-high-reliability

September 12, 2018 - Review Transferring aviation practices into clinical medicine for the promotion of high reliability. Citation Text: Powell-Dunford N, McPherson MK, Pina JS, et al. Transferring Aviation Practices into Clinical Medicine for the Promotion of High Reliability. Aerosp Med Hum Perform. 2017;8…

Patient safety culture in primary care: developing a theoretical framework for practical use. | PSNet

psnet.ahrq.gov/issue/patient-safety-culture-primary-care-developing-theoretical-framework-practical-use

September 06, 2017 - Study Patient safety culture in primary care: developing a theoretical framework for practical use. Citation Text: Kirk S, Parker D, Claridge T, et al. Patient safety culture in primary care: developing a theoretical framework for practical use. Qual Saf Health Care. 2007;16(4):313-20.…

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…

Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems. | PSNet

psnet.ahrq.gov/issue/comparison-prototype-indications-based-prescribing-2-commercial-prescribing-systems

June 05, 2018 - Study Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems. Citation Text: Garabedian PM, Wright A, Newbury I, et al. Comparison of a Prototype for Indications-Based Prescribing With 2 Commercial Prescribing Systems. JAMA Netw Open. 2019;2(3):…

Hospitals as cultures of entrapment: a re-analysis of the Bristol Royal Infirmary. | PSNet

psnet.ahrq.gov/issue/hospitals-cultures-entrapment-re-analysis-bristol-royal-infirmary

May 21, 2019 - Commentary Classic Hospitals as cultures of entrapment: a re-analysis of the Bristol Royal Infirmary. Citation Text: Weick KE, Sutcliffe KM. Hospitals as Cultures of Entrapment: A Re-Analysis of the Bristol Royal Infirmary. Calif Manage Rev. 2012;45(2):73-84. do…

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…

Preventable anesthesia mishaps: a study of human factors. | PSNet

psnet.ahrq.gov/issue/preventable-anesthesia-mishaps-study-human-factors

June 23, 2015 - Study Classic Preventable anesthesia mishaps: a study of human factors. Citation Text: Cooper JB, Newbower RS, Long CD, et al. Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978;49(6):399-406. Copy Citation Format: Goo…

Overview of adverse events related to invasive procedures in the intensive care unit. | PSNet

psnet.ahrq.gov/issue/overview-adverse-events-related-invasive-procedures-intensive-care-unit

November 29, 2023 - Study Overview of adverse events related to invasive procedures in the intensive care unit. Citation Text: Pottier V, Daubin C, Lerolle N, et al. Overview of adverse events related to invasive procedures in the intensive care unit. Am J Infect Control. 2012;40(3):241-6. doi:10.1016/j.a…

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