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  1. Guidelines in Practice: prevention of unintentionally retained surgical items. | PSNet

    psnet.ahrq.gov/issue/guidelines-practice-prevention-unintentionally-retained-surgical-items
    August 03, 2022 - Commentary Guidelines in Practice: prevention of unintentionally retained surgical items. Citation Text: Cochran K. Guidelines in Practice: prevention of unintentionally retained surgical items. AORN J. 2022;116(5):427-440. doi:10.1002/aorn.13804. Copy Citation Format: DOI …

  2. 'They were his best shot. And they failed to help’: why did EMS workers neglect Tyre Nichols? | PSNet

    psnet.ahrq.gov/issue/they-were-his-best-shot-and-they-failed-help-why-did-ems-workers-neglect-tyre-nichols
    July 19, 2023 - Newspaper/Magazine Article 'They were his best shot. And they failed to help’: why did EMS workers neglect Tyre Nichols? Citation Text: 'They were his best shot. And they failed to help’: why did EMS workers neglect Tyre Nichols? Renault M. STAT. February 6, 2023. Copy Citation …

  3. Prevent medication errors: a New Year's resolution: teaching patients about their medications. | PSNet

    psnet.ahrq.gov/issue/prevent-medication-errors-new-years-resolution-teaching-patients-about-their-medications
    January 18, 2011 - Commentary Prevent medication errors: a New Year's resolution: teaching patients about their medications. Citation Text: Polzien G. Prevent medication errors: A New Year's resolution: teaching patients about their medications. Home Healthc Nurse. 2007;25(1):59-62. Copy Citation F…

  4. The safety culture in a children's hospital. | PSNet

    psnet.ahrq.gov/issue/safety-culture-childrens-hospital
    October 06, 2011 - Study The safety culture in a children's hospital. Citation Text: Grant MJC, Donaldson AE, Larsen G. The safety culture in a children's hospital. J Nurs Care Qual. 2006;21(3):223-229. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …

  5. Performing an inadvertent procedure. | PSNet

    psnet.ahrq.gov/issue/performing-inadvertent-procedure
    October 16, 2019 - Commentary Performing an inadvertent procedure. Citation Text: Gupta A, Jain S, Croft C. Performing an Inadvertent Procedure. JAMA. 2019;321(5):504-505. doi:10.1001/jama.2018.21438. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …

  6. Track 6: Using Reporting Systems for Safety and Quality Improvement | Digital Healthcare Research

    digital.ahrq.gov/track-6-using-reporting-systems-safety-and-quality-improvement
    January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…

  7. Global Report on Infection Prevention and Control: Executive Summary. | PSNet

    psnet.ahrq.gov/issue/global-report-infection-prevention-and-control-executive-summary
    March 09, 2022 - Book/Report Global Report on Infection Prevention and Control: Executive Summary. Citation Text: Global Report on Infection Prevention and Control: Executive Summary. Geneva, Switzerland; World Health Organization; May 5, 2022. Copy Citation Save Save to your li…

  8. Keeping patients safe in healthcare organizations: a structuration theory of safety culture. | PSNet

    psnet.ahrq.gov/issue/keeping-patients-safe-healthcare-organizations-structuration-theory-safety-culture
    September 04, 2010 - Review Keeping patients safe in healthcare organizations: a structuration theory of safety culture. Citation Text: Groves PS, Meisenbach RJ, Scott-Cawiezell J. Keeping patients safe in healthcare organizations: a structuration theory of safety culture. J Adv Nurs. 2011;67(8):1846-55. d…

  9. Designing a strategy to promote safe, innovative off-label use of medications. | PSNet

    psnet.ahrq.gov/issue/designing-strategy-promote-safe-innovative-label-use-medications
    May 06, 2009 - Commentary Designing a strategy to promote safe, innovative off-label use of medications. Citation Text: Ansani N, Sirio CA, Smitherman T, et al. Designing a strategy to promote safe, innovative off-label use of medications. Am J Med Qual. 2006;21(4):255-261. Copy Citation Format…

  10. Pathology and patient safety: the critical role of pathology informatics in error reduction and quality initiatives. | PSNet

    psnet.ahrq.gov/issue/pathology-and-patient-safety-critical-role-pathology-informatics-error-reduction-and-quality
    July 20, 2009 - Review Pathology and patient safety: the critical role of pathology informatics in error reduction and quality initiatives. Citation Text: Becich MJ, Gilbertson JR, Gupta D, et al. Pathology and patient safety: the critical role of pathology informatics in error reduction and quality i…

  11. Safety cultural preconditions for organizational learning in high-risk organizations. | PSNet

    psnet.ahrq.gov/issue/safety-cultural-preconditions-organizational-learning-high-risk-organizations
    June 17, 2009 - Commentary Safety cultural preconditions for organizational learning in high-risk organizations. Citation Text: Naevestad T-O. Safety Cultural Preconditions for Organizational Learning in High-Risk Organizations. J Contingencies Crisis Manage. 2008;16(3):154-163. doi:10.1111/j.1468-5973.…

  12. Recognizing the importance of whistleblowers in healthcare. | PSNet

    psnet.ahrq.gov/issue/recognizing-importance-whistleblowers-healthcare
    June 24, 2009 - Commentary Recognizing the importance of whistleblowers in healthcare. Citation Text: O'Neill N. Recognizing the importance of whistleblowers in healthcare. Nursing (Brux). 2021;51(4):54-56. doi:10.1097/01.nurse.0000736912.14380.65. Copy Citation Format: DOI Google Scholar …

  13. Effective approaches to control non-actionable alarms and alarm fatigue. | PSNet

    psnet.ahrq.gov/issue/effective-approaches-control-non-actionable-alarms-and-alarm-fatigue
    January 15, 2025 - Commentary Effective approaches to control non-actionable alarms and alarm fatigue. Citation Text: Winters BD. Effective approaches to control non-actionable alarms and alarm fatigue. J Electrocardiol. 2018;51(6S):S49-S51. doi:10.1016/j.jelectrocard.2018.07.007. Copy Citation Forma…

  14. Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane. | PSNet

    psnet.ahrq.gov/issue/senators-threaten-consequences-after-va-confirms-4-deaths-tied-computer-system-tested-spokane
    September 21, 2022 - Newspaper/Magazine Article Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane. Citation Text: Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane. Donovan-Smith O. Spokesman Review. March 15,…

  15. Life after death: the aftermath of perioperative catastrophes. | PSNet

    psnet.ahrq.gov/issue/life-after-death-aftermath-perioperative-catastrophes
    March 29, 2012 - Review Life after death: the aftermath of perioperative catastrophes. Citation Text: Gazoni FM, Durieux ME, Wells L. Life after death: the aftermath of perioperative catastrophes. Anesth Analg. 2008;107(2):591-600. doi:10.1213/ane.0b013e31817a9c77. Copy Citation Format: D…

  16. Improving patient safety in radiation oncology. | PSNet

    psnet.ahrq.gov/issue/improving-patient-safety-radiation-oncology
    September 23, 2020 - Meeting/Conference Proceedings Improving patient safety in radiation oncology. Citation Text: Hendee WR, Herman MG. Improving patient safety in radiation oncology. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  17. SAFER Electronic Health Records: Safety Assurance Factors for EHR Resilience. | PSNet

    psnet.ahrq.gov/issue/safer-electronic-health-records-safety-assurance-factors-ehr-resilience
    December 20, 2017 - Book/Report SAFER Electronic Health Records: Safety Assurance Factors for EHR Resilience. Citation Text: SAFER Electronic Health Records: Safety Assurance Factors for EHR Resilience. Sittig DF, Singh H, eds. Waretown, NJ: Apple Academic Press; 2015. ISBN: 9781771881173. Copy Citation …

  18. Patient death after inadvertent infusion of PRN medication hanging on bedside intravenous (IV) pole. | PSNet

    psnet.ahrq.gov/issue/patient-death-after-inadvertent-infusion-prn-medication-hanging-bedside-intravenous-iv-pole
    April 17, 2024 - Newspaper/Magazine Article Patient death after inadvertent infusion of PRN medication hanging on bedside intravenous (IV) pole. Citation Text: Patient death after inadvertent infusion of PRN medication hanging on bedside intravenous (IV) pole. ISMP Medication Safety Alert! Acute Care. 20…

  19. Evaluating teamwork in a simulated obstetric environment. | PSNet

    psnet.ahrq.gov/issue/evaluating-teamwork-simulated-obstetric-environment
    November 04, 2009 - Study Evaluating teamwork in a simulated obstetric environment. Citation Text: Morgan PJ, Pittini R, Regehr G, et al. Evaluating teamwork in a simulated obstetric environment. Anesthesiology. 2007;106(5):907-915. Copy Citation Format: Google Scholar PubMed BibTeX EndNote …

  20. Overcoming diagnostic errors in medical practice. | PSNet

    psnet.ahrq.gov/issue/overcoming-diagnostic-errors-medical-practice
    March 15, 2017 - Commentary Overcoming diagnostic errors in medical practice. Citation Text: Bordini BJ, Stephany A, Kliegman RM. Overcoming Diagnostic Errors in Medical Practice. J Pediatr. 2017;185. doi:10.1016/j.jpeds.2017.02.065. Copy Citation Format: DOI Google Scholar BibTeX EndNote X…
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