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  1. Stories from the sharp end: case studies in safety improvement. | PSNet

    psnet.ahrq.gov/issue/stories-sharp-end-case-studies-safety-improvement
    October 07, 2008 - Study Stories from the sharp end: case studies in safety improvement. Citation Text: Stories from the sharp end: case studies in safety improvement. McCarthy D; Blumenthal D. Milbank Q. 2006;84(1):165-200 Copy Citation Save Save to your library Print Dow…

  2. Using smart pumps to understand and evaluate clinician practice patterns to ensure patient safety. | PSNet

    psnet.ahrq.gov/issue/using-smart-pumps-understand-and-evaluate-clinician-practice-patterns-ensure-patient-safety
    September 01, 2016 - Study Using smart pumps to understand and evaluate clinician practice patterns to ensure patient safety. Citation Text: Mansfield J, Jarrett S. Using smart pumps to understand and evaluate clinician practice patterns to ensure patient safety. Hosp Pharm. 2013;48(11):942-950. doi:10.1310…

  3. The impact of organisational and individual factors on team communication in surgery: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/impact-organisational-and-individual-factors-team-communication-surgery-qualitative-study
    March 23, 2011 - Study The impact of organisational and individual factors on team communication in surgery: a qualitative study. Citation Text: Gillespie BM, Chaboyer W, Longbottom P, et al. The impact of organisational and individual factors on team communication in surgery: a qualitative study. Int …

  4. Medication-related clinical decision support in computerized provider order entry systems: a review. | PSNet

    psnet.ahrq.gov/issue/medication-related-clinical-decision-support-computerized-provider-order-entry-systems-review
    March 11, 2011 - Review Medication-related clinical decision support in computerized provider order entry systems: a review. Citation Text: Kuperman GJ, Bobb A, Payne TH, et al. Medication-related clinical decision support in computerized provider order entry systems: a review. J Am Med Inform Assoc. 2…

  5. IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events. | PSNet

    psnet.ahrq.gov/issue/ihi-skilled-nursing-facility-trigger-tool-measuring-adverse-events
    February 15, 2017 - Book/Report IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events. Citation Text: IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events. Adler L, Moore J, Federico F. Cambridge, MA: Institute for Healthcare Improvement; November 2015. Copy Citation …

  6. Human factors engineering: its place and potential in OR safety. | PSNet

    psnet.ahrq.gov/issue/human-factors-engineering-its-place-and-potential-or-safety
    May 24, 2017 - Commentary Human factors engineering: its place and potential in OR safety. Citation Text: Criscitelli T. Human factors engineering: its place and potential in OR safety. AORN J. 2015;101(5):571-3. doi:10.1016/j.aorn.2015.02.013. Copy Citation Format: DOI Google Scholar Pub…

  7. Operating management system for high reliability: leadership, accountability, learning and innovation in healthcare. | PSNet

    psnet.ahrq.gov/issue/operating-management-system-high-reliability-leadership-accountability-learning-and
    July 01, 2016 - Commentary Operating management system for high reliability: leadership, accountability, learning and innovation in healthcare. Citation Text: Day RM, Demski RJ, Pronovost PJ, et al. Operating management system for high reliability: Leadership, accountability, learning and innovation in …

  8. Medical Device Use Error: Root Cause Analysis. | PSNet

    psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis
    January 10, 2018 - Book/Report Medical Device Use Error: Root Cause Analysis. Citation Text: Medical Device Use Error: Root Cause Analysis. Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790. Copy Citation Save Save to your library Print Down…

  9. Driving improvement in patient care: lessons from Toyota. | PSNet

    psnet.ahrq.gov/issue/driving-improvement-patient-care-lessons-toyota
    September 24, 2016 - Study Classic Driving improvement in patient care: lessons from Toyota. Citation Text: Thompson DN, Wolf GA, Spear SJ. Driving improvement in patient care: lessons from Toyota. J Nurs Adm. 2003;33(11):585-595. Copy Citation Format: Google Scholar …

  10. Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief. | PSNet

    psnet.ahrq.gov/issue/pain-management-and-prescription-opioid-related-harms-exploring-state-evidence-proceedings
    July 05, 2008 - Meeting/Conference Proceedings Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief. Citation Text: Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Works…

  11. Rapid response systems as a patient safety strategy: a systematic review. | PSNet

    psnet.ahrq.gov/issue/rapid-response-systems-patient-safety-strategy-systematic-review
    March 20, 2013 - Review Rapid response systems as a patient safety strategy: a systematic review. Citation Text: Winters BD, Weaver SJ, Pfoh ER, et al. Rapid-response systems as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):417-25. doi:10.7326/0003-4819-158-5-201303051…

  12. The limits of checklists: handoff and narrative thinking. | PSNet

    psnet.ahrq.gov/issue/limits-checklists-handoff-and-narrative-thinking
    July 01, 2017 - Commentary The limits of checklists: handoff and narrative thinking. Citation Text: Hilligoss B, Moffatt-Bruce SD. The limits of checklists: handoff and narrative thinking. BMJ Qual Saf. 2014;23(7):528-33. doi:10.1136/bmjqs-2013-002705. Copy Citation Format: DOI Google Scho…

  13. Clinical decision support in the era of artificial intelligence. | PSNet

    psnet.ahrq.gov/issue/clinical-decision-support-era-artificial-intelligence
    November 06, 2015 - Commentary Classic Clinical decision support in the era of artificial intelligence. Citation Text: Shortliffe EH, Sepúlveda MJ. Clinical Decision Support in the Era of Artificial Intelligence. JAMA. 2018;320(21):2199-2200. doi:10.1001/jama.2018.17163. Copy Cit…

  14. Missed nursing care: a concept analysis. | PSNet

    psnet.ahrq.gov/issue/missed-nursing-care-concept-analysis
    January 19, 2022 - Commentary Missed nursing care: a concept analysis. Citation Text: Kalisch BJ, Landstrom GL, Hinshaw AS. Missed nursing care: a concept analysis. J Adv Nurs. 2009;65(7):1509-17. doi:10.1111/j.1365-2648.2009.05027.x. Copy Citation Format: DOI Google Scholar PubMed BibTeX End…

  15. Diagnosing overdiagnosis: conceptual challenges and suggested solutions. | PSNet

    psnet.ahrq.gov/issue/diagnosing-overdiagnosis-conceptual-challenges-and-suggested-solutions
    September 20, 2023 - Commentary Diagnosing overdiagnosis: conceptual challenges and suggested solutions. Citation Text: Hofmann B. Diagnosing overdiagnosis: conceptual challenges and suggested solutions. Eur J Epidemiol. 2014;29(9):599-604. doi:10.1007/s10654-014-9920-5. Copy Citation Format: D…

  16. The effect of drug concentration expression on epinephrine dosing errors: a randomized trial. | PSNet

    psnet.ahrq.gov/issue/effect-drug-concentration-expression-epinephrine-dosing-errors-randomized-trial
    August 27, 2008 - Study The effect of drug concentration expression on epinephrine dosing errors: a randomized trial. Citation Text: Wheeler DW, Carter JJ, Murray LJ, et al. The effect of drug concentration expression on epinephrine dosing errors: a randomized trial. Ann Intern Med. 2008;148(1):11-4. …

  17. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. | PSNet

    psnet.ahrq.gov/issue/advancing-science-measurement-diagnostic-errors-healthcare-safer-dx-framework
    December 06, 2023 - Commentary Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. Citation Text: Singh H, Sittig DF. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. BMJ Qual Saf. 2015;24(2):103-110. doi:10.1136/bm…

  18. Wrong-site craniotomy: analysis of 35 cases and systems for prevention. | PSNet

    psnet.ahrq.gov/issue/wrong-site-craniotomy-analysis-35-cases-and-systems-prevention
    November 16, 2022 - Study Wrong-site craniotomy: analysis of 35 cases and systems for prevention. Citation Text: Cohen FL, Mendelsohn D, Bernstein M. Wrong-site craniotomy: analysis of 35 cases and systems for prevention. J Neurosurg. 2010;113(3):461-73. doi:10.3171/2009.10.JNS091282. Copy Citation …

  19. Handoff communication between hospital and outpatient dialysis units at patient discharge: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/handoff-communication-between-hospital-and-outpatient-dialysis-units-patient-discharge
    August 20, 2018 - Study Handoff communication between hospital and outpatient dialysis units at patient discharge: a qualitative study. Citation Text: Reilly JB, Marcotte LM, Berns JS, et al. Handoff communication between hospital and outpatient dialysis units at patient discharge: a qualitative study. …

  20. Prevent errors during emergency use of hypertonic sodium chloride solutions. | PSNet

    psnet.ahrq.gov/issue/prevent-errors-during-emergency-use-hypertonic-sodium-chloride-solutions
    March 10, 2021 - Newspaper/Magazine Article Prevent errors during emergency use of hypertonic sodium chloride solutions. Citation Text: Prevent errors during emergency use of hypertonic sodium chloride solutions. ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4. Copy Citat…
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