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Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system. | PSNet

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January 12, 2022 - Commentary Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system. Citation Text: Schnoor J, Rogalski C, Frontini R, et al. Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system. Patien…

Identifying modifiable barriers to medication error reporting in the nursing home setting. | PSNet

psnet.ahrq.gov/issue/identifying-modifiable-barriers-medication-error-reporting-nursing-home-setting

March 10, 2011 - Study Identifying modifiable barriers to medication error reporting in the nursing home setting. Citation Text: Handler S, Perera S, Olshansky EF, et al. Identifying modifiable barriers to medication error reporting in the nursing home setting. J Am Med Dir Assoc. 2007;8(9):568-74. C…

Confirming delivery: understanding the role of the hospitalized patient in medication administration safety. | PSNet

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March 02, 2016 - Study Confirming delivery: understanding the role of the hospitalized patient in medication administration safety. Citation Text: Macdonald M, Heilemann MS, MacKinnon NJ, et al. Confirming delivery: understanding the role of the hospitalized patient in medication administration safety. Q…

Developing a patient measure of safety (PMOS). | PSNet

psnet.ahrq.gov/issue/developing-patient-measure-safety-pmos

June 25, 2014 - Study Developing a patient measure of safety (PMOS). Citation Text: Giles SJ, Lawton R, Din I, et al. Developing a patient measure of safety (PMOS). BMJ Qual Saf. 2013;22(7):554-62. doi:10.1136/bmjqs-2012-000843. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndN…

Can a structured checklist prevent problems with laparoscopic equipment? | PSNet

psnet.ahrq.gov/issue/can-structured-checklist-prevent-problems-laparoscopic-equipment

August 10, 2016 - Study Can a structured checklist prevent problems with laparoscopic equipment? Citation Text: Verdaasdonk EGG, Stassen LPS, Hoffmann WF, et al. Can a structured checklist prevent problems with laparoscopic equipment? Surg Endosc. 2008;22(10):2238-43. doi:10.1007/s00464-008-0029-3. Co…

Improving transfusion safety: implementation of a comprehensive computerized bar code-based tracking system for detecting and preventing errors. | PSNet

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October 19, 2022 - Study Improving transfusion safety: implementation of a comprehensive computerized bar code-based tracking system for detecting and preventing errors. Citation Text: Askeland RW, McGrane S, Levitt JS, et al. Improving transfusion safety: implementation of a comprehensive computerized b…

Cost-effectiveness of an electronic medication ordering and administration system in reducing adverse drug events. | PSNet

psnet.ahrq.gov/issue/cost-effectiveness-electronic-medication-ordering-and-administration-system-reducing-adverse

June 01, 2012 - Study Cost-effectiveness of an electronic medication ordering and administration system in reducing adverse drug events. Citation Text: Wu RC, Laporte A, Ungar WJ. Cost-effectiveness of an electronic medication ordering and administration system in reducing adverse drug events. J Eval …

Work-arounds and artifacts during transition to a computer physician order entry: what they are and what they mean. | PSNet

psnet.ahrq.gov/issue/work-arounds-and-artifacts-during-transition-computer-physician-order-entry-what-they-are-and

January 12, 2022 - Study Work-arounds and artifacts during transition to a computer physician order entry: what they are and what they mean. Citation Text: Schoville RR. Work-arounds and artifacts during transition to a computer physician order entry: what they are and what they mean. J Nurs Care Qual. 2…

Implementation of standardized dosing units for I.V. medications. | PSNet

psnet.ahrq.gov/issue/implementation-standardized-dosing-units-iv-medications

May 11, 2014 - Study Implementation of standardized dosing units for I.V. medications. Citation Text: Jung B, Couldry R, Wilkinson S, et al. Implementation of standardized dosing units for i.v. medications. Am J Health Syst Pharm. 2014;71(24):2153-8. doi:10.2146/ajhp140046. Copy Citation Format: …

An analysis of near misses identified by anesthesia providers in the intensive care unit. | PSNet

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August 17, 2017 - Study An analysis of near misses identified by anesthesia providers in the intensive care unit. Citation Text: Lipshutz AKM, Caldwell JE, Robinowitz DL, et al. An analysis of near misses identified by anesthesia providers in the intensive care unit. BMC Anesthesiol. 2015;15:93. doi:10.11…

Deploying Six Sigma in a health care system as a work in progress. | PSNet

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March 04, 2011 - Study Deploying Six Sigma in a health care system as a work in progress. Citation Text: Christianson JB, Warrick LH, Howard R, et al. Deploying Six Sigma in a health care system as a work in progress. Jt Comm J Qual Patient Saf. 2005;31(11):603-13. Copy Citation Format: Goo…

Hospital inpatient nutrition service errors and patient safety interventions: a scoping review. | PSNet

psnet.ahrq.gov/issue/hospital-inpatient-nutrition-service-errors-and-patient-safety-interventions-scoping-review

January 01, 2000 - Review Hospital inpatient nutrition service errors and patient safety interventions: a scoping review. Citation Text: Austria D, McConnell C, Pope C. Hospital inpatient nutrition service errors and patient safety interventions: a scoping review. J Patient Saf. 2024;20(4):272-278. doi:10.…

EHR safety: the way forward to safe and effective systems. | PSNet

psnet.ahrq.gov/issue/ehr-safety-way-forward-safe-and-effective-systems

December 12, 2012 - Commentary EHR safety: the way forward to safe and effective systems. Citation Text: Walker JM, Carayon P, Leveson N, et al. EHR safety: the way forward to safe and effective systems. J Am Med Inform Assoc. 2008;15(3):272-7. doi:10.1197/jamia.M2618. Copy Citation Format: …

Case study research: the view from complexity science. | PSNet

psnet.ahrq.gov/issue/case-study-research-view-complexity-science

January 03, 2017 - Commentary Case study research: the view from complexity science. Citation Text: Anderson RA, Crabtree B, Steele DJ, et al. Case study research: the view from complexity science. Qual Health Res. 2005;15(5):669-85. Copy Citation Format: Google Scholar PubMed BibTeX EndNote …

Perioperative patient safety recommendations: systematic review of clinical practice guidelines. | PSNet

psnet.ahrq.gov/issue/perioperative-patient-safety-recommendations-systematic-review-clinical-practice-guidelines

January 08, 2025 - Study Perioperative patient safety recommendations: systematic review of clinical practice guidelines. Citation Text: Martínez-Nicolas I, Arnal-Velasco D, Romero-García E, et al. Perioperative patient safety recommendations: systematic review of clinical practice guidelines. BJS Open. 20…

Collaboration between pharmacists, physicians and nurse practitioners: a qualitative investigation of working relationships in the inpatient medical setting. | PSNet

psnet.ahrq.gov/issue/collaboration-between-pharmacists-physicians-and-nurse-practitioners-qualitative

November 16, 2022 - Study Collaboration between pharmacists, physicians and nurse practitioners: a qualitative investigation of working relationships in the inpatient medical setting. Citation Text: Makowsky MJ, Schindel TJ, Rosenthal M, et al. Collaboration between pharmacists, physicians and nurse pract…

AHRQ announces interest in health services research to reduce emergency department boarding and hospital crowding. | PSNet

psnet.ahrq.gov/issue/ahrq-announces-interest-health-services-research-reduce-emergency-department-boarding-and

November 12, 2008 - Press Release/Announcement AHRQ announces interest in health services research to reduce emergency department boarding and hospital crowding. Citation Text: AHRQ announces interest in health services research to reduce emergency department boarding and hospital crowding. Agency for Healt…

Controlled substance drug diversion by healthcare workers as a threat to patient safety. | PSNet

psnet.ahrq.gov/issue/controlled-substance-drug-diversion-healthcare-workers-threat-patient-safety

April 05, 2023 - Special or Theme Issue Controlled substance drug diversion by healthcare workers as a threat to patient safety. Citation Text: Controlled substance drug diversion by healthcare workers as a threat to patient safety. ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4…

Variations by state in physician disciplinary actions by US medical licensure boards. | PSNet

psnet.ahrq.gov/issue/variations-state-physician-disciplinary-actions-us-medical-licensure-boards

March 12, 2025 - Study Variations by state in physician disciplinary actions by US medical licensure boards. Citation Text: Harris JA, Byhoff E. Variations by state in physician disciplinary actions by US medical licensure boards. BMJ Qual Saf. 2017;26(3):200-208. doi:10.1136/bmjqs-2015-004974. Copy Ci…

Healthcare staff wellbeing, burnout, and patient safety: a systematic review. | PSNet

psnet.ahrq.gov/issue/healthcare-staff-wellbeing-burnout-and-patient-safety-systematic-review

November 13, 2024 - Review Healthcare staff wellbeing, burnout, and patient safety: a systematic review. Citation Text: Hall LH, Johnson J, Watt I, et al. Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review. PLoS One. 2016;11(7):e0159015. doi:10.1371/journal.pone.0159015. Copy Cit…

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