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  1. Using information from external errors to signal a "clear and present danger." | PSNet

    psnet.ahrq.gov/issue/using-information-external-errors-signal-clear-and-present-danger
    March 14, 2023 - Newspaper/Magazine Article Using information from external errors to signal a "clear and present danger." Citation Text: Using information from external errors to signal a "clear and present danger." ISMP Medication Safety Alert! Acute care edition. February 9, 2017;22:1-5. Copy Citati…

  2. Airway carts: a systems-based approach to airway safety. | PSNet

    psnet.ahrq.gov/issue/airway-carts-systems-based-approach-airway-safety
    July 21, 2010 - Study Airway carts: a systems-based approach to airway safety. Citation Text: Kane BG, Bond WF, Worrilow CC, et al. Airway Carts. J Patient Saf. 2008;2(3). doi:10.1097/01.jps.0000242995.09037.07. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

  3. A crisis within a crisis. | PSNet

    psnet.ahrq.gov/issue/crisis-within-crisis
    May 05, 2021 - Newspaper/Magazine Article A crisis within a crisis. Citation Text: A crisis within a crisis. Ellis NT, Broaddus A. CNN. August 25, 2021.  Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter …

  4. Malnutrition in Hospitalized Adults: A Systematic Review. | PSNet

    psnet.ahrq.gov/issue/malnutrition-hospitalized-adults-systematic-review
    December 21, 2022 - Book/Report Malnutrition in Hospitalized Adults: A Systematic Review. Citation Text: Malnutrition in Hospitalized Adults: A Systematic Review. Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2021.  AHRQ Publication No. 21(22)…

  5. EAU policy on live surgery events. | PSNet

    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. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndN…

  6. Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN. | PSNet

    psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn
    June 24, 2020 - Newspaper/Magazine Article Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN. Citation Text: Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN. Gillispie-Bell V. USA Today. April 14, 2023. Copy Citation S…

  7. High-risk, high-alert medication management practices in a regional state psychiatric facility. | PSNet

    psnet.ahrq.gov/issue/high-risk-high-alert-medication-management-practices-regional-state-psychiatric-facility
    January 06, 2017 - Study High-risk, high-alert medication management practices in a regional state psychiatric facility. Citation Text: McKee J, Cleary S. High-Risk, High-Alert Medication Management Practices in a Regional State Psychiatric Facility. Hosp Pharm. 2007;42(4):323-330. doi:10.1310/hpj4204-323.…

  8. Improving care transitions: current practice and future opportunities for pharmacists. | PSNet

    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…

  9. Assessing and monitoring override medications in automated dispensing devices. | PSNet

    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. Copy Citation F…

  10. Education is “predictably disappointing” and should never be relied upon alone to improve safety. | PSNet

    psnet.ahrq.gov/issue/education-predictably-disappointing-and-should-never-be-relied-upon-alone-improve-safety
    June 15, 2022 - Newspaper/Magazine Article Education is “predictably disappointing” and should never be relied upon alone to improve safety. Citation Text: Education is “predictably disappointing” and should never be relied upon alone to improve safety. ISMP Medication Safety Alert! Acute care edition. …

  11. Restoring trust in VA health care. | PSNet

    psnet.ahrq.gov/issue/restoring-trust-va-health-care
    June 21, 2016 - Commentary Restoring trust in VA health care. Citation Text: Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014;371(4):295-297. doi:10.1056/NEJMp1406852. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …

  12. Dangers and deaths around black pregnancies seen as a ‘completely preventable’ health crisis. | PSNet

    psnet.ahrq.gov/issue/dangers-and-deaths-around-black-pregnancies-seen-completely-preventable-health-crisis
    August 16, 2023 - Newspaper/Magazine Article Dangers and deaths around black pregnancies seen as a ‘completely preventable’ health crisis. Citation Text: Dangers and deaths around black pregnancies seen as a ‘completely preventable’ health crisis. West S. KFF Health News. August 24, 2023. Copy Citatio…

  13. Root cause analysis. | PSNet

    psnet.ahrq.gov/issue/root-cause-analysis
    June 15, 2016 - Commentary Root cause analysis. Citation Text: Stecker MS. Root cause analysis. J Vasc Interv Radiol. 2007;18(1 Pt 1):5-8. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation …

  14. Developing process-support tools for patient safety: finding the balance between validity and feasibility. | PSNet

    psnet.ahrq.gov/issue/developing-process-support-tools-patient-safety-finding-balance-between-validity-and
    January 20, 2010 - Commentary Developing process-support tools for patient safety: finding the balance between validity and feasibility. Citation Text: Marsteller JA, Holzmueller CG, Makary MA, et al. Developing process-support tools for patient safety: finding the balance between validity and feasibility.…

  15. Enteral feeding misconnections: a consortium position statement. | PSNet

    psnet.ahrq.gov/issue/enteral-feeding-misconnections-consortium-position-statement
    June 17, 2009 - Organizational Policy/Guidelines Enteral feeding misconnections: a consortium position statement. Citation Text: Guenter P, Hicks RW, Simmons D, et al. Enteral feeding misconnections: a consortium position statement. Jt Comm J Qual Patient Saf. 2008;34(5):285-92, 245. Copy Citation …

  16. Increasing demands for quality measurement. | PSNet

    psnet.ahrq.gov/issue/increasing-demands-quality-measurement
    November 16, 2022 - Commentary Increasing demands for quality measurement. Citation Text: Panzer RJ, Gitomer RS, Greene WH, et al. Increasing demands for quality measurement. JAMA. 2013;310(18):1971-80. doi:10.1001/jama.2013.282047. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNo…

  17. Theorizing about systems: an ecological task for patient safety research. | PSNet

    psnet.ahrq.gov/issue/theorizing-about-systems-ecological-task-patient-safety-research
    August 20, 2008 - Commentary Theorizing about systems: an ecological task for patient safety research. Citation Text: Marck PB. Theorizing About Systems. Clin Nurs Res. 2005;14(2). doi:10.1177/1054773804274255. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…

  18. The Safety of Maternity Services in England. | PSNet

    psnet.ahrq.gov/issue/safety-maternity-services-england
    February 04, 2015 - Book/Report The Safety of Maternity Services in England. Citation Text: The Safety of Maternity Services in England. Fourth Report of Session 2021–22. House of Commons Health Committee. London, England: The Stationery Office; July 6, 2021. Publication HC 19.  Copy Citation …

  19. Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility. | PSNet

    psnet.ahrq.gov/issue/paralyzed-mistakes-reassess-safety-neuromuscular-blockers-your-facility
    July 27, 2016 - Newspaper/Magazine Article Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility. Citation Text: Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility. ISMP Medication Safety Alert! Acute Care Edition. June 16, 2016;21:1-6. …

  20. Improving hospital performance: culture change is not the answer. | PSNet

    psnet.ahrq.gov/issue/improving-hospital-performance-culture-change-not-answer
    September 27, 2016 - Commentary Improving hospital performance: culture change is not the answer. Citation Text: Leggat SG, Dwyer J. Improving hospital performance: culture change is not the answer. Healthc Q. 2005;8(2):60-6. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML E…
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