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psnet.ahrq.gov/issue/national-healthcare-system-action-alliance-advance-patient-safety
April 01, 2024 - Multi-use Website
The National Healthcare System Action Alliance for Patient and Workforce Safety.
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The National Healthcare System Action Alliance for Patient and Workforce Safety. US Department of Health and Human Services.
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psnet.ahrq.gov/issue/evolving-hospital-quality-star-rating-system-cms-aligning-stars
December 13, 2017 - Commentary
An evolving hospital quality star rating system from CMS: aligning the stars.
Citation Text:
Bilimoria KY, Barnard C. An evolving hospital quality star rating system from CMS: aligning the stars. JAMA. 2021;325(21):2151-2152. doi:10.1001/jama.2021.6946.
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psnet.ahrq.gov/issue/role-automation-complex-system-failures
June 28, 2013 - Commentary
The role of automation in complex system failures.
Citation Text:
Perry SJ, Wears RL, Cook RI. The role of automation in complex system failures. J Patient Saf. 2005;1(1):56-61. https://journals.lww.com/journalpatientsafety/Fulltext/2005/03000/The_Role_of_Automation_in_Compl…
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psnet.ahrq.gov/issue/survey-results-pharmacists-provide-support-enhance-organizational-response-codes
November 02, 2022 - Newspaper/Magazine Article
Survey results from pharmacists provide support to enhance the organizational response to codes.
Citation Text:
Survey results from pharmacists provide support to enhance the organizational response to codes. ISMP Medication Safety Alert! Acute care edition. Oc…
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psnet.ahrq.gov/issue/make-no-mistake-about-it-chain-pharmacies-are-finding-innovative-ways-combat-medication
May 20, 2020 - Newspaper/Magazine Article
Make no mistake about it: chain pharmacies are finding innovative ways to combat medication errors.
Citation Text:
Make no mistake about it: chain pharmacies are finding innovative ways to combat medication errors. Levy S. Drug Topics. July 9, 2007
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psnet.ahrq.gov/issue/documenting-day-discussion-ahead-crest-wave-creating-national-agenda-systemic-change-enhanced
April 28, 2021 - Book/Report
Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change for Enhanced Clinician Well-Being.
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Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change …
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psnet.ahrq.gov/issue/junior-doctors-shifts-and-sleep-deprivation
October 16, 2012 - Commentary
Junior doctors' shifts and sleep deprivation.
Citation Text:
Murray A, Pounder R, Mather H, et al. Junior doctors' shifts and sleep deprivation. BMJ. 2005;330(7505):1404.
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psnet.ahrq.gov/issue/toolkit-preventing-clabsi-and-cauti-icus
December 24, 2008 - Toolkit
Toolkit for Preventing CLABSI and CAUTI in ICUs.
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Toolkit for Preventing CLABSI and CAUTI in ICUs. Rockville, MD: Agency for Healthcare Research and Quality; April 2022.
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psnet.ahrq.gov/issue/adverse-events-toolkit-medical-record-review-methodology
July 19, 2023 - Book/Report
Adverse Events Toolkit: Medical Record Review Methodology.
Citation Text:
Adverse Events Toolkit: Medical Record Review Methodology. Maxwell A. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2023. Report no. OEI-06-21-00…
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psnet.ahrq.gov/issue/eau-policy-live-surgery-events
December 29, 2014 - Review
EAU policy on live surgery events.
Citation Text:
Artibani W, Ficarra V, Challacombe BJ, et al. EAU policy on live surgery events. Eur Urol. 2014;66(1):87-97. doi:10.1016/j.eururo.2014.01.028.
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psnet.ahrq.gov/issue/system-failure-versus-personal-accountability-case-clean-hands
February 16, 2011 - Commentary
System failure versus personal accountability--the case for clean hands.
Citation Text:
Goldmann DA. System failure versus personal accountability--the case for clean hands. N Engl J Med. 2006;355(2):121-3.
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psnet.ahrq.gov/issue/transformation-health-care-front-line
July 24, 2017 - Commentary
Transformation of health care at the front line.
Citation Text:
Conway PH, Clancy CM. Transformation of health care at the front line. JAMA. 2009;301(7):763-5. doi:10.1001/jama.2009.103.
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psnet.ahrq.gov/issue/err-human-apologize-hard
September 28, 2022 - Commentary
To err is human, to apologize is hard.
Citation Text:
Krakower TM. To err Is human, to apologize is hard. JAMA. 2021;326(3):223-224. doi:10.1001/jama.2021.10840.
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psnet.ahrq.gov/issue/appropriate-prescribing-medications-eight-step-approach
January 10, 2024 - Commentary
Appropriate prescribing of medications: an eight-step approach.
Citation Text:
Pollock M, Bazaldua O, Dobbie AE. Appropriate prescribing of medications: an eight-step approach. Am Fam Physician. 2007;75(2):231-236.
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psnet.ahrq.gov/issue/cybersecurity-patient-safety-policy-options-health-care-sector
December 16, 2020 - Book/Report
Cybersecurity is Patient Safety: Policy Options in the Health Care Sector.
Citation Text:
Cybersecurity is Patient Safety: Policy Options in the Health Care Sector. Washington DC; Office of Senator Mark Warner: November 25, 2022.
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psnet.ahrq.gov/issue/prescription-drug-monitoring-programs-evidence-based-practices-optimize-prescriber-use
September 19, 2018 - Book/Report
Prescription Drug Monitoring Programs: Evidence-based Practices to Optimize Prescriber Use.
Citation Text:
Prescription Drug Monitoring Programs: Evidence-based Practices to Optimize Prescriber Use. Philadelphia, PA: Pew Charitable Trusts and Institute for Behavioral Health, …
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psnet.ahrq.gov/issue/assessing-and-monitoring-override-medications-automated-dispensing-devices
May 06, 2009 - Study
Assessing and monitoring override medications in automated dispensing devices.
Citation Text:
Kowiatek JG, Weber RJ, Skledar S, et al. Assessing and monitoring override medications in automated dispensing devices. Jt Comm J Qual Patient Saf. 2006;32(6):309-17.
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psnet.ahrq.gov/issue/taking-risky-business-out-mri-suite
September 12, 2016 - Newspaper/Magazine Article
Taking risky business out of the MRI suite.
Citation Text:
Rozovsky FA, Gilk TB, Latina RJ. Managing liability exposure and safety. Taking risky business out of the MRI suite. Materials management in health care. 2006;15(1):18-23.
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psnet.ahrq.gov/issue/quality-and-economic-impact-disruptive-behaviors-clinical-outcomes-patient-care
February 03, 2010 - Commentary
The quality and economic impact of disruptive behaviors on clinical outcomes of patient care.
Citation Text:
Rosenstein AH. The quality and economic impact of disruptive behaviors on clinical outcomes of patient care. Am J Med Qual. 2011;26(5):372-9. doi:10.1177/106286061140…
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psnet.ahrq.gov/issue/improving-care-transitions-current-practice-and-future-opportunities-pharmacists
December 12, 2012 - Commentary
Improving care transitions: current practice and future opportunities for pharmacists.
Citation Text:
Pharmacy AC of C, Hume AL, Kirwin J, et al. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012;32(11):e326-37. doi…