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  1. Implementation of a specialized pharmacy team to monitor high-risk medications during discharge. | PSNet

    psnet.ahrq.gov/issue/implementation-specialized-pharmacy-team-monitor-high-risk-medications-during-discharge
    September 23, 2020 - Commentary Implementation of a specialized pharmacy team to monitor high-risk medications during discharge. Citation Text: Martin ES, Overstreet RL, Jackson-Khalil LR, et al. Implementation of a specialized pharmacy team to monitor high-risk medications during discharge. Am J Health S…

  2. Discrepancies between prescribed and actual pediatric home parenteral nutrition solutions. | PSNet

    psnet.ahrq.gov/issue/discrepancies-between-prescribed-and-actual-pediatric-home-parenteral-nutrition-solutions
    November 11, 2009 - Study Discrepancies between prescribed and actual pediatric home parenteral nutrition solutions. Citation Text: Raphael BP, Murphy M, Gura KM, et al. Discrepancies Between Prescribed and Actual Pediatric Home Parenteral Nutrition Solutions. Nutr Clin Pract. 2016;31(5):654-658. doi:10.117…

  3. Litigation related to drug errors in anaesthesia: an analysis of claims against the NHS in England 1995-2007. | PSNet

    psnet.ahrq.gov/issue/litigation-related-drug-errors-anaesthesia-analysis-claims-against-nhs-england-1995-2007
    November 12, 2014 - Study Litigation related to drug errors in anaesthesia: an analysis of claims against the NHS in England 1995-2007. Citation Text: Cranshaw J, Gupta KJ, Cook TM. Litigation related to drug errors in anaesthesia: an analysis of claims against the NHS in England 1995-2007. Anaesthesia. 2…

  4. Burden of hospitalizations related to adverse drug events in the USA: a retrospective analysis from large inpatient database. | PSNet

    psnet.ahrq.gov/issue/burden-hospitalizations-related-adverse-drug-events-usa-retrospective-analysis-large
    April 15, 2020 - Study Burden of hospitalizations related to adverse drug events in the USA: a retrospective analysis from large inpatient database. Citation Text: Poudel DR, Acharya P, Ghimire S, et al. Burden of hospitalizations related to adverse drug events in the USA: a retrospective analysis from l…

  5. Mapping changes in surgical mortality over 9 years by peer review audit. | PSNet

    psnet.ahrq.gov/issue/mapping-changes-surgical-mortality-over-9-years-peer-review-audit
    March 04, 2011 - Study Mapping changes in surgical mortality over 9 years by peer review audit. Citation Text: Thompson A, Ashraf Z, Burton H, et al. Mapping changes in surgical mortality over 9 years by peer review audit. Br J Surg. 2005;92(11):1449-52. Copy Citation Format: Google Schol…

  6. Failures in communication and information transfer across the surgical care pathway: interview study. | PSNet

    psnet.ahrq.gov/issue/failures-communication-and-information-transfer-across-surgical-care-pathway-interview-study
    August 09, 2013 - Study Failures in communication and information transfer across the surgical care pathway: interview study. Citation Text: Nagpal K, Arora S, Vats A, et al. Failures in communication and information transfer across the surgical care pathway: interview study. BMJ Qual Saf. 2012;21(10):8…

  7. Safety culture and care: a program to prevent surgical errors. | PSNet

    psnet.ahrq.gov/issue/safety-culture-and-care-program-prevent-surgical-errors
    March 25, 2020 - Commentary Safety culture and care: a program to prevent surgical errors. Citation Text: Hemingway MW, O'Malley C, Silvestri S. Safety culture and care: a program to prevent surgical errors. AORN J. 2015;101(4):404-12; quiz 413-5. doi:10.1016/j.aorn.2015.01.002. Copy Citation Forma…

  8. Connected care: reducing errors through automated vital signs data upload. | PSNet

    psnet.ahrq.gov/issue/connected-care-reducing-errors-through-automated-vital-signs-data-upload
    September 01, 2018 - Study Connected care: reducing errors through automated vital signs data upload. Citation Text: Smith LB, Banner L, Lozano D, et al. Connected care: reducing errors through automated vital signs data upload. Comput Inform Nurs. 2009;27(5):318-23. doi:10.1097/NCN.0b013e3181b21d65. Cop…

  9. The computerized rounding report: implementation of a model system to support transitions of care. | PSNet

    psnet.ahrq.gov/issue/computerized-rounding-report-implementation-model-system-support-transitions-care
    October 19, 2022 - Study The computerized rounding report: implementation of a model system to support transitions of care. Citation Text: Wohlauer M, Rove KO, Pshak TJ, et al. The computerized rounding report: implementation of a model system to support transitions of care. J Surg Res. 2012;172(1):11-7.…

  10. Gaps in the continuity of care and progress on patient safety. | PSNet

    psnet.ahrq.gov/issue/gaps-continuity-care-and-progress-patient-safety
    January 16, 2017 - Commentary Classic Gaps in the continuity of care and progress on patient safety. Citation Text: Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ. 2000;320(7237):791-4. Copy Citation Format: Google Sch…

  11. Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model. | PSNet

    psnet.ahrq.gov/issue/effectiveness-surgical-safety-checklist-correcting-errors-literature-review-applying-reasons
    January 10, 2018 - Review Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model. Citation Text: Collins SJ, Newhouse R, Porter J, et al. Effectiveness of the surgical safety checklist in correcting errors: a literature review applying …

  12. Implementation of a "second victim" program in a pediatric hospital. | PSNet

    psnet.ahrq.gov/issue/implementation-second-victim-program-pediatric-hospital
    December 18, 2013 - Study Implementation of a "second victim" program in a pediatric hospital. Citation Text: Krzan KD, Merandi J, Morvay S, et al. Implementation of a "second victim" program in a pediatric hospital. Am J Health Syst Pharm. 2015;72(7):563-7. doi:10.2146/ajhp140650. Copy Citation Forma…

  13. Predictors of unit-level medication administration accuracy: microsystem impacts on medication safety. | PSNet

    psnet.ahrq.gov/issue/predictors-unit-level-medication-administration-accuracy-microsystem-impacts-medication
    October 06, 2016 - Study Predictors of unit-level medication administration accuracy: microsystem impacts on medication safety. Citation Text: Donaldson N, Aydin C, Fridman M. Predictors of unit-level medication administration accuracy: microsystem impacts on medication safety. J Nurs Adm. 2014;44(6):353-6…

  14. A qualitative exploration of patients' attitudes towards the 'Participate Inform Notice Know' (PINK) patient safety video. | PSNet

    psnet.ahrq.gov/issue/qualitative-exploration-patients-attitudes-towards-participate-inform-notice-know-pink
    July 06, 2012 - Study A qualitative exploration of patients' attitudes towards the 'Participate Inform Notice Know' (PINK) patient safety video. Citation Text: Pinto A, Vincent CA, Darzi A, et al. A qualitative exploration of patients' attitudes towards the 'Participate Inform Notice Know' (PINK) patien…

  15. A prospective risk assessment of informal carers' medication administration errors within the domiciliary setting. | PSNet

    psnet.ahrq.gov/issue/prospective-risk-assessment-informal-carers-medication-administration-errors-within
    February 08, 2017 - Study A prospective risk assessment of informal carers' medication administration errors within the domiciliary setting. Citation Text: Parand A, Faiella G, Franklin BD, et al. A prospective risk assessment of informal carers' medication administration errors within the domiciliary setti…

  16. Optimising the delivery of remediation programmes for doctors: a realist review. | PSNet

    psnet.ahrq.gov/issue/optimising-delivery-remediation-programmes-doctors-realist-review
    June 02, 2021 - Review Optimising the delivery of remediation programmes for doctors: a realist review. Citation Text: Price T, Wong G, Withers L, et al. Optimising the delivery of remediation programmes for doctors: a realist review. Med Educ. 2021;55(9):995-1010. doi:10.1111/medu.14528. Copy Citatio…

  17. Using near-miss events to improve MRI safety in a large academic centre. | PSNet

    psnet.ahrq.gov/issue/using-near-miss-events-improve-mri-safety-large-academic-centre
    May 31, 2017 - Commentary Using near-miss events to improve MRI safety in a large academic centre. Citation Text: Goolsarran N, Martinez J, Garcia C. Using near-miss events to improve MRI safety in a large academic centre. BMJ Open Qual. 2019;8(2):e000593. doi:10.1136/bmjoq-2018-000593. Copy Citation…

  18. International perspectives on modifications to the surgical safety checklist. | PSNet

    psnet.ahrq.gov/issue/international-perspectives-modifications-surgical-safety-checklist
    November 17, 2021 - Study International perspectives on modifications to the surgical safety checklist. Citation Text: Turley N, Elam M, Brindle ME. International perspectives on modifications to the surgical safety checklist. JAMA Netw Open. 2023;6(6):e2317183. doi:10.1001/jamanetworkopen.2023.17183. Cop…

  19. Rapid response team in a rural hospital. | PSNet

    psnet.ahrq.gov/issue/rapid-response-team-rural-hospital
    October 19, 2022 - Study Rapid response team in a rural hospital. Citation Text: Brown S, Anderson MA, Hill PD. Rapid response team in a rural hospital. Clin Nurse Spec. 2012;26(2):95-102. doi:10.1097/NUR.0b013e31824590fb. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML…

  20. Hospital system barriers to rapid response team activation: a cognitive work analysis. | PSNet

    psnet.ahrq.gov/issue/hospital-system-barriers-rapid-response-team-activation-cognitive-work-analysis
    September 09, 2015 - Study Hospital system barriers to rapid response team activation: a cognitive work analysis. Citation Text: Braaten JS. CE: Original research: hospital system barriers to rapid response team activation: a cognitive work analysis. Am J Nurs. 2015;115(2):22-32; test 33; 47. doi:10.1097/01.…
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