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  1. psnet.ahrq.gov/issue/improving-medication-management-through-redesign-hospital-code-cart-medication-drawer
    October 31, 2018 - Study Improving medication management through the redesign of the hospital code cart medication drawer. Citation Text: Rousek JB, Hallbeck MS. Improving Medication Management Through the Redesign of the Hospital Code Cart Medication Drawer. Human Factors: The Journal of the Human Facto…
  2. psnet.ahrq.gov/issue/errors-and-omissions-hospital-prescriptions-survey-prescription-writing-hospital
    April 13, 2022 - Study Errors and omissions in hospital prescriptions: a survey of prescription writing in a hospital. Citation Text: Calligaris L, Panzera A, Arnoldo L, et al. Errors and omissions in hospital prescriptions: a survey of prescription writing in a hospital. BMC Clin Pharmacol. 2009;9:9. d…
  3. psnet.ahrq.gov/issue/miscoding-misclassification-and-misdiagnosis-diabetes-primary-care
    September 23, 2020 - Study Miscoding, misclassification and misdiagnosis of diabetes in primary care. Citation Text: de Lusignan S, Sadek N, Mulnier H, et al. Miscoding, misclassification and misdiagnosis of diabetes in primary care. Diabet Med. 2012;29(2):181-9. doi:10.1111/j.1464-5491.2011.03419.x. Cop…
  4. psnet.ahrq.gov/issue/standard-drug-concentrations-and-smart-pump-technology-reduce-continuous-medication-infusion
    October 06, 2011 - Study Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients. Citation Text: Larsen G, Parker HB, Cash J, et al. Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in ped…
  5. psnet.ahrq.gov/issue/quality-journey-ascension-health-how-weve-prevented-least-1500-avoidable-deaths-year-and-aim
    June 06, 2018 - Commentary The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths a year—and aim to do even better. Citation Text: Pryor D, Hendrich A, Henkel RJ, et al. The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths…
  6. psnet.ahrq.gov/issue/utilizing-information-technology-mitigate-handoff-risks-caused-resident-work-hour
    March 17, 2010 - Commentary Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions. Citation Text: Bernstein J, MacCourt DC, Jacob DM, et al. Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions. Clin …
  7. psnet.ahrq.gov/issue/theoretical-framework-and-competency-based-approach-improving-handoffs
    March 28, 2011 - Commentary A theoretical framework and competency-based approach to improving handoffs. Citation Text: Arora VM, Johnson JK, Meltzer DO, et al. A theoretical framework and competency-based approach to improving handoffs. Qual Saf Health Care. 2008;17(1):11-4. doi:10.1136/qshc.2006.0189…
  8. psnet.ahrq.gov/issue/medication-complexity-medication-number-and-their-relationships-medication-discrepancies
    November 16, 2022 - Study Medication complexity, medication number, and their relationships to medication discrepancies. Citation Text: Patel CH, Zimmerman KM, Fonda JR, et al. Medication Complexity, Medication Number, and Their Relationships to Medication Discrepancies. Ann Pharmacother. 2016;50(7):534-40.…
  9. psnet.ahrq.gov/issue/therapeutic-errors-involving-adults-community-setting-nature-causes-and-outcomes
    May 24, 2009 - Study Therapeutic errors involving adults in the community setting: nature, causes and outcomes. Citation Text: Taylor D, Robinson J, MacLeod D, et al. Therapeutic errors involving adults in the community setting: nature, causes and outcomes. Aust N Z J Public Health. 2009;33(4):388-94…
  10. psnet.ahrq.gov/issue/feasibility-centre-based-incident-reporting-primary-healthcare-spiegel-study
    October 05, 2011 - Study Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL study. Citation Text: Zwart DLM, Steerneman AHM, van Rensen ELJ, et al. Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL study. BMJ Qual Saf. 2011;20(2):121-7. doi:1…
  11. psnet.ahrq.gov/issue/blending-evidence-and-innovation-improving-intershift-handoffs-multihospital-setting
    September 23, 2017 - Commentary Blending evidence and innovation: improving intershift handoffs in a multihospital setting. Citation Text: Thomas L, Donohue-Porter P. Blending evidence and innovation: improving intershift handoffs in a multihospital setting. J Nurs Care Qual. 2012;27(2):116-24. doi:10.1097…
  12. psnet.ahrq.gov/issue/management-arterial-lines-and-blood-sampling-intensive-care-threat-patient-safety
    November 12, 2014 - Study Management of arterial lines and blood sampling in intensive care: a threat to patient safety. Citation Text: Leslie RA, Gouldson S, Habib N, et al. Management of arterial lines and blood sampling in intensive care: a threat to patient safety. Anaesthesia. 2013;68(11). doi:10.1111…
  13. psnet.ahrq.gov/issue/prospective-memory-icu-effect-visual-cues-task-execution-representative-simulation
    April 24, 2018 - Study Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. Citation Text: Grundgeiger T, Sanderson PM, Orihuela B, et al. Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. Ergo…
  14. psnet.ahrq.gov/issue/developing-framework-nursing-handover-emergency-department-individualised-and-systematic
    October 06, 2016 - Study Developing a framework for nursing handover in the emergency department: an individualised and systematic approach. Citation Text: Klim S, Kelly A-M, Kerr D, et al. Developing a framework for nursing handover in the emergency department: an individualised and systematic approach. …
  15. psnet.ahrq.gov/issue/evidence-guiding-practice-reported-versus-observed-adherence-contact-precautions-pilot-study
    June 28, 2017 - Study Is evidence guiding practice? Reported versus observed adherence to contact precautions: a pilot study. Citation Text: Jessee MA, Mion LC. Is evidence guiding practice? Reported versus observed adherence to contact precautions: a pilot study. Am J Infect Control. 2013;41(11):965-…
  16. psnet.ahrq.gov/issue/health-care-huddles-managing-complexity-achieve-high-reliability
    November 17, 2015 - Study Health care huddles: managing complexity to achieve high reliability. Citation Text: Provost SM, Lanham H, Leykum LK, et al. Health care huddles: managing complexity to achieve high reliability. Health Care Manage Rev. 2015;40(1):2-12. doi:10.1097/HMR.0000000000000009. Copy Citat…
  17. psnet.ahrq.gov/issue/drug-formulations-require-potentially-inaccurate-volumes-prepare-doses-infants-and-children
    April 22, 2011 - Study Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children. Citation Text: Uppal N, Yasseen B, Seto W, et al. Drug formulations that require less than 0.1 mL of stock solution to prepare doses for infants and children. CMAJ. 2011;183(4…
  18. psnet.ahrq.gov/issue/nature-and-occurrence-registration-errors-emergency-department
    September 28, 2016 - Study The nature and occurrence of registration errors in the emergency department. Citation Text: Hakimzada AF, Green RA, Sayan OR, et al. The nature and occurrence of registration errors in the emergency department. Int J Med Inform. 2007;77(3). doi:10.1016/j.ijmedinf.2007.04.011. …
  19. psnet.ahrq.gov/issue/engaging-front-line-tapping-hospital-wide-quality-and-safety-initiatives
    March 20, 2019 - Commentary Engaging the front line: tapping into hospital-wide quality and safety initiatives. Citation Text: Wolpaw J, Schwengel D, Hensley N, et al. Engaging the Front Line: Tapping into Hospital-Wide Quality and Safety Initiatives. J Cardiothorac Vasc Anesth. 2018;32(1):522-533. doi:1…
  20. psnet.ahrq.gov/issue/listening-and-question-asking-behaviors-resident-and-nurse-handoff-conversations-prospective
    June 27, 2018 - Study Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study. Citation Text: Kannampallil TG, Abraham J. Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study.…

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