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psnet.ahrq.gov/issue/its-sending-message-bottle-qualitative-study-consequences-one-way-communication-technologies
December 02, 2020 - Study
It's like sending a message in a bottle: a qualitative study of the consequences of one-way communication technologies in hospitals.
Citation Text:
Lafferty M, Harrod M, Krein SL, et al. It’s like sending a message in a bottle: a qualitative study of the consequences of one-way com…
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psnet.ahrq.gov/issue/understanding-informal-aspects-medication-processes-maintain-patient-safety-hospitals
March 06, 2024 - Study
Understanding the informal aspects of medication processes to maintain patient safety in hospitals: a sociotechnical ethnographic study in paediatric units.
Citation Text:
Sutherland AB, Phipps DL, Grant S, et al. Understanding the informal aspects of medication processes to mainta…
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psnet.ahrq.gov/issue/systematic-review-clinical-outcomes-associated-intrahospital-transitions
October 02, 2019 - Review
A systematic review of clinical outcomes associated with intrahospital transitions
Citation Text:
Bristol AA, Schneider CE, Lin S-Y, et al. A Systematic Review of Clinical Outcomes Associated With Intrahospital Transitions. J Healthc Qual. 2019. doi:10.1097/JHQ.0000000000000232.
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psnet.ahrq.gov/issue/communication-and-collaboration-its-about-pharmacists-well-physicians-and-nurses
November 25, 2009 - Study
Communication and collaboration: it's about the pharmacists, as well as the physicians and nurses.
Citation Text:
Holden LM, Watts DD, Walker PH. Communication and collaboration: it's about the pharmacists, as well as the physicians and nurses. Qual Saf Health Care. 2010;19(3):16…
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psnet.ahrq.gov/issue/safety-ii-behavior-pediatric-intensive-care-unit
January 12, 2022 - Study
Safety II behavior in a pediatric intensive care unit.
Citation Text:
Merandi J, Vannatta K, Davis T, et al. Safety II Behavior in a Pediatric Intensive Care Unit. Pediatrics. 2018;141(6):e20180018. doi:10.1542/peds.2018-0018.
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psnet.ahrq.gov/issue/cardiac-surgery-errors-results-uk-national-reporting-and-learning-system
May 24, 2012 - Study
Cardiac surgery errors: results from the UK National Reporting and Learning System.
Citation Text:
Martinez EA, Shore AD, Colantuoni E, et al. Cardiac surgery errors: results from the UK National Reporting and Learning System. Int J Qual Health Care. 2011;23(2):151-8. doi:10.1093/i…
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psnet.ahrq.gov/issue/bayesian-cohort-and-cross-sectional-analyses-pincer-trial-pharmacist-led-intervention-reduce
December 21, 2022 - Study
Bayesian cohort and cross-sectional analyses of the PINCER trial: a pharmacist-led intervention to reduce medication errors in primary care.
Citation Text:
Hemming K, Chilton PJ, Lilford RJ, et al. Bayesian cohort and cross-sectional analyses of the PINCER trial: a pharmacist-led…
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psnet.ahrq.gov/issue/electronic-health-record-interoperability-why-electronically-discontinued-medications-are
August 25, 2021 - Commentary
Electronic health record interoperability-why electronically discontinued medications are still dispensed.
Citation Text:
Shervani S, Madden W, Gleason LJ. Electronic health record interoperability-why electronically discontinued medications are still dispensed. JAMA Intern Me…
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psnet.ahrq.gov/issue/pharmacy-e-prescription-dispensing-and-after-cancelrx-implementation
October 05, 2022 - Study
Pharmacy e-prescription dispensing before and after CancelRx implementation.
Citation Text:
Pitts SI, Olson S, Yanek LR, et al. Pharmacy e-prescription dispensing before and after CancelRx implementation. JAMA Intern Med. 2023;183(10):1120-1126. doi:10.1001/jamainternmed.2023.4192.…
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psnet.ahrq.gov/issue/patterns-technical-error-among-surgical-malpractice-claims-analysis-strategies-prevent-injury
August 26, 2011 - Study
Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients.
Citation Text:
Regenbogen SE, Greenberg CC, Studdert DM, et al. Patterns of technical error among surgical malpractice claims: an analysis of strategie…
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psnet.ahrq.gov/issue/patient-safety-education-20-years-after-institute-medicine-report-results-cross-sectional
October 19, 2022 - Study
Patient safety education 20 years after the Institute of Medicine report: results from a cross-sectional national survey.
Citation Text:
Arora S, Tsang F, Kekecs Z, et al. Patient safety education 20 years after the Institute of Medicine report: results from a cross-sectional natio…
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psnet.ahrq.gov/issue/focus-patient-safety
January 23, 2008 - Book/Report
Focus on Patient Safety.
Citation Text:
Focus on Patient Safety. Annu Rev Nurs Res. 2006;24:1-331.
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psnet.ahrq.gov/node/33809/psn-pdf
June 01, 2016 - Working on culture without focusing on burnout and joy and meaning will not give us the results we need … Just focusing on joy and meaning without really looking at culture and leadership is also going to be
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - The second skill is team leadership, focusing on maximizing every team member's potential, which is particularly … TeamSTEPPS provides a helpful framework for creating effective teams focusing on communication, leadership
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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - RW: So, if you were trying to accelerate this pace, would you be focusing on creating a business case … RW: When David Brailer became the IT czar, I think he surprised some outsiders by focusing so strongly
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psnet.ahrq.gov/node/33696/psn-pdf
June 01, 2010 - RW: You ended up focusing on cognitive errors and diagnostic errors. … So we turned our M&M rounds
around, focusing on cognitive errors, affective errors, biases, distortions
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - She has directed projects with multiple stakeholders focusing on Medicare Part D Medication Therapy Management … the Director of Medical Education Research and Innovation in the Medical Education Outcomes Center, focusing
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psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - Although caregiver collaboration is improving and organizations are focusing less on individual blame
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psnet.ahrq.gov/node/33647/psn-pdf
March 01, 2007 - For example, the physician-patient mentioned above tried to engage senior
leadership in focusing the
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psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
February 01, 2014 - working on accelerating patient safety improvement in nursing homes and in ambulatory care—particularly focusing … Our research is focusing on how health IT can be designed and used to improve care, particularly looking … We are constantly focusing on how to make sure that what we do changes policy and practice.