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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.
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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.
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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.
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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.…
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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.
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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.
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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.
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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.
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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. …
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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.
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psnet.ahrq.gov/issue/latent-and-active-failures-perfectly-align-allow-preventable-adverse-event-reach-patient
March 14, 2023 - Newspaper/Magazine Article
Latent and active failures perfectly align to allow a preventable adverse event to reach a patient.
Citation Text:
Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. ISMP Medication Safety Alert! Acute care editi…
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psnet.ahrq.gov/issue/medication-errors-year-review
May 02, 2018 - Newspaper/Magazine Article
Medication errors: the year in review.
Citation Text:
Medication errors: the year in review. Valentine D, Ingram V, Fobi B et al. Pharmacy Practice News. September 10, 2019.
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psnet.ahrq.gov/issue/stepping-out-further-shadows-disclosure-harmful-radiologic-errors-patients
April 21, 2011 - Commentary
Stepping out further from the shadows: disclosure of harmful radiologic errors to patients.
Citation Text:
Brown SD, Lehman CD, Truog RD, et al. Stepping Out Further from the Shadows: Disclosure of Harmful Radiologic Errors to Patients. Radiology. 2012;262(2):381-386. doi:10…
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psnet.ahrq.gov/issue/nurses-guilty-verdict-dosing-mistake-could-cost-lives
April 27, 2022 - Newspaper/Magazine Article
Nurses: Guilty verdict for dosing mistake could cost lives.
Citation Text:
Nurses: Guilty verdict for dosing mistake could cost lives. Loller T. Associated Press. March 30, 2022.
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psnet.ahrq.gov/issue/handoff-checklists-improve-reliability-patient-handoffs-operating-room-and-postanesthesia
December 29, 2014 - Study
Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit.
Citation Text:
Boat AC, Spaeth JP. Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. Paediatr Anaes…
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psnet.ahrq.gov/issue/patient-safety-listen-whistleblowers
May 22, 2019 - Commentary
Patient safety: listen to whistleblowers.
Citation Text:
Kirkup B, Titcombe J. Patient safety: listen to whistleblowers. BMJ. 2023;382:1972. doi:10.1136/bmj.p1972.
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psnet.ahrq.gov/issue/reducing-harm-patients-using-patient-safety-dashboards-board-level
February 22, 2010 - Newspaper/Magazine Article
Reducing harm to patients. Using patient safety dashboards at the board level.
Citation Text:
Pugh M, Reinertsen JL. Reducing harm to patients. Using patient safety dashboards at the board level. Healthcare executive. 2007;22(6):62, 64-5.
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psnet.ahrq.gov/issue/tackling-implicit-bias-health-care
December 01, 2021 - Commentary
Tackling implicit bias in health care.
Citation Text:
Sabin JA. Tackling implicit bias in health care. N Engl J Med. 2022;387(2):105-107. doi:10.1056/nejmp2201180.
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psnet.ahrq.gov/issue/home-medical-device-safety-tops-ecris-list-healthcare-technology
February 08, 2023 - Newspaper/Magazine Article
Home medical device safety tops ECRI'S list of healthcare technology.
Citation Text:
Home medical device safety tops ECRI'S list of healthcare technology. Wicklund E. HealthLeaders. January 19, 2023.
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psnet.ahrq.gov/issue/physical-environments-promote-safe-medication-use
December 19, 2018 - Commentary
Physical environments that promote safe medication use.
Citation Text:
Grissinger M. Physical environments that promote safe medication use. PT. 2012;37(7):377-378.
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