-
psnet.ahrq.gov/node/866255/psn-pdf
July 10, 2024 - Cyberattack led to harrowing lapses at Ascension
hospitals, clinicians say.
July 10, 2024
Pradhan R, Wells K. KFF Health News and Morning Edition, Michigan Public Radio: June 19, 2024.
https://psnet.ahrq.gov/issue/cyberattack-led-harrowing-lapses-ascension-hospitals-clinicians-say
Cybersecurity is increasingly see…
-
psnet.ahrq.gov/node/39214/psn-pdf
January 03, 2017 - Medical trainees' formal and informal incident reporting
across a five-hospital academic medical center.
January 3, 2017
Logio LS, Ramanujam R. Medical trainees' formal and informal incident reporting across a five-hospital
academic medical center. Jt Comm J Qual Patient Saf. 2010;36(1):36-42.
https://psnet.ahrq.g…
-
psnet.ahrq.gov/node/44407/psn-pdf
April 15, 2016 - Frequency and severity of parenteral nutrition medication
errors at a large children's hospital after implementation
of electronic ordering and compounding.
April 15, 2016
MacKay M, Anderson C, Boehme S, et al. Frequency and Severity of Parenteral Nutrition Medication Errors
at a Large Children's Hospital After Im…
-
psnet.ahrq.gov/node/837211/psn-pdf
May 25, 2022 - 4 actions to reduce medical errors in U.S. hospitals.
May 25, 2022
Toussaint JS, Segel KT. Harvard Business Review. April 20, 2022.
https://psnet.ahrq.gov/issue/4-actions-reduce-medical-errors-us-hospitals
The patient safety movement has had mixed results in sustaining improvement and commitment. This
comment…
-
psnet.ahrq.gov/node/34644/psn-pdf
December 23, 2008 - Medication-prescribing errors in a teaching hospital: a 9-
year experience.
December 23, 2008
Lesar TS, Lomaestro BM, Pohl H. Medication-prescribing errors in a teaching hospital. A 9-year
experience. Arch Intern Med. 1997;157(14):1569-76.
https://psnet.ahrq.gov/issue/medication-prescribing-errors-teaching-hospita…
-
psnet.ahrq.gov/node/42539/psn-pdf
September 27, 2016 - Causes of medication administration errors in hospitals: a
systematic review of quantitative and qualitative
evidence.
September 27, 2016
Keers RN, Williams SD, Cooke J, et al. Causes of medication administration errors in hospitals: a
systematic review of quantitative and qualitative evidence. Drug Saf. 2013;36(1…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.323_slideshow.ppt
May 01, 2014 - PowerPoint Presentation
Spotlight
Medication Reconciliation With a Twist (or Dare We Say, a Patch?)
This presentation is based on the May 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Janice Kwan, MD, Department of Medicine, University of Tor…
-
psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - A Mid-Summer Fog
Citation Text:
Braddock CH. A Mid-Summer Fog. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
-
psnet.ahrq.gov/issue/how-real-time-data-can-change-patient-safety-game
July 07, 2021 - Commentary
How real-time data can change the patient safety game.
Citation Text:
Diesing G. How real-time data can change the patient safety game. J AHIMA. 2020;July 1.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
-
psnet.ahrq.gov/issue/covid-19-and-healthcare-facilities-decalogue-design-strategies-resilient-hospitals
February 23, 2022 - Commentary
COVID-19 and healthcare facilities: a decalogue of design strategies for resilient hospitals.
Citation Text:
COVID-19 and healthcare facilities: a decalogue of design strategies for resilient hospitals. Capolongo S, Gola M, Brambilla A, et al. Acta Biomed. 2020;91(9-s):50-60.&…
-
psnet.ahrq.gov/issue/patient-safety-developing-countries-retrospective-estimation-scale-and-nature-harm-patients
March 23, 2011 - Study
Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital.
Citation Text:
Wilson R, Michel P, Olsen S, et al. Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hos…
-
psnet.ahrq.gov/issue/does-insulin-double-checking-procedure-improve-patient-safety
April 24, 2018 - Study
Does an insulin double-checking procedure improve patient safety?
Citation Text:
Modic MB, Albert NM, Sun Z, et al. Does an Insulin Double-Checking Procedure Improve Patient Safety? J Nurs Adm. 2016;46(3):154-60. doi:10.1097/NNA.0000000000000314.
Copy Citation
Format:
…
-
psnet.ahrq.gov/issue/implementing-fatigue-countermeasures-program-nurses-focus-group-analysis
February 19, 2010 - Study
Implementing a fatigue countermeasures program for nurses: a focus group analysis.
Citation Text:
Scott LD, Hofmeister N, Rogness N, et al. Implementing a fatigue countermeasures program for nurses: a focus group analysis. J Nurs Adm. 2010;40(5):233-40. doi:10.1097/NNA.0b013e3181d…
-
psnet.ahrq.gov/issue/navigating-care-transitions-process-model-how-doctors-overcome-organizational-barriers-and
February 20, 2016 - Study
Navigating care transitions: a process model of how doctors overcome organizational barriers and create awareness.
Citation Text:
Hilligoss B, Vogus TJ. Navigating Care Transitions. Medical Care Research and Review. 2014;72(1). doi:10.1177/1077558714563170.
Copy Citation
Form…
-
psnet.ahrq.gov/issue/patient-safety-culture-factors-influence-clinician-involvement-patient-safety-behaviours
April 16, 2014 - Study
Patient safety culture: factors that influence clinician involvement in patient safety behaviours.
Citation Text:
Wakefield JG, McLaws M-L, Whitby M, et al. Patient safety culture: factors that influence clinician involvement in patient safety behaviours. Qual Saf Health Care. 20…
-
psnet.ahrq.gov/issue/workarounds-use-healthcare-case-study-electronic-medication-administration-system
June 29, 2011 - Study
Workarounds in the use of IS in healthcare: a case study of an electronic medication administration system.
Citation Text:
Yang Z, Ng B-Y, Kankanhalli A, et al. Workarounds in the use of IS in healthcare: A case study of an electronic medication administration system. Internation…
-
psnet.ahrq.gov/issue/opioids-medicare-part-d-concerns-about-extreme-use-and-questionable-prescribing
October 29, 2008 - Book/Report
Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing.
Citation Text:
Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing. Office of the Inspector General. Washington, DC: US Department of Health and Human Services…
-
psnet.ahrq.gov/issue/getting-message-quality-improvement-initiative-reduce-pages-sent-wrong-physician
April 30, 2014 - Study
Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician.
Citation Text:
Wong BM, Cheung M, Dharamshi H, et al. Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician. BMJ Qual Saf. 2012;21(10):85…
-
psnet.ahrq.gov/issue/factors-associated-disclosure-medical-errors-housestaff
January 27, 2019 - Study
Factors associated with disclosure of medical errors by housestaff.
Citation Text:
Kronman AC, Paasche-Orlow MK, Orlander JD. Factors associated with disclosure of medical errors by housestaff. BMJ Qual Saf. 2011;21(4). doi:10.1136/bmjqs-2011-000084.
Copy Citation
Format:
…
-
psnet.ahrq.gov/issue/preventing-medication-errors-hospitals-through-systems-approach-and-technological-innovation
September 11, 2019 - Commentary
Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010.
Citation Text:
Crane J, Crane FG. Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for…