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psnet.ahrq.gov/issue/does-applying-technology-throughout-medication-use-process-improve-patient-safety
October 30, 2024 - Review
Does applying technology throughout the medication use process improve patient safety with antineoplastics?
Citation Text:
Bubalo J, Warden BA, Wiegel JJ, et al. Does applying technology throughout the medication use process improve patient safety with antineoplastics? J Oncol Pha…
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psnet.ahrq.gov/issue/managing-cognitive-biases-during-disaster-response-development-aide-memoire
November 16, 2022 - Review
Managing cognitive biases during disaster response: the development of an aide memoire.
Citation Text:
Brooks B, Curnin S, Owen C, et al. Managing cognitive biases during disaster response: the development of an aide memoire. Cogn Tech Work. 2020;22(2):249–261. doi:10.1007/s10111-…
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psnet.ahrq.gov/issue/guide-evaluation-quality-improvement-and-patient-safety-educational-programs-lessons-va-chief
February 26, 2020 - Commentary
A guide to evaluation of quality improvement and patient safety educational programs: lessons from the VA Chief Resident in Quality and Safety Program.
Citation Text:
Butcher RL, Carluzzo KL, Watts B, et al. A Guide to Evaluation of Quality Improvement and Patient Safety Educa…
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psnet.ahrq.gov/issue/analysis-prescribers-notes-electronic-prescriptions-ambulatory-practice
July 23, 2018 - Study
Analysis of prescribers' notes in electronic prescriptions in ambulatory practice.
Citation Text:
Dhavle AA, Yang Y, Rupp MT, et al. Analysis of Prescribers' Notes in Electronic Prescriptions in Ambulatory Practice. JAMA Intern Med. 2016;176(4):463-70. doi:10.1001/jamainternmed.201…
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psnet.ahrq.gov/issue/enteral-nutrition-underappreciated-source-patient-safety-events
February 01, 2023 - Study
Enteral nutrition: an underappreciated source of patient safety events.
Citation Text:
Citty SW, Chew M, Hiller LD, et al. Enteral nutrition: an underappreciated source of patient safety events. Nutr Clin Prac. 2024;39(4):784-799. doi:10.1002/ncp.11153.
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psnet.ahrq.gov/issue/early-prognostic-value-medical-emergency-team-calling-criteria-patients-admitted-intensive
March 24, 2021 - Study
Early prognostic value of the medical emergency team calling criteria in patients admitted to intensive care from the emergency department.
Citation Text:
Etter R, Ludwig R, Lersch F, et al. Early prognostic value of the medical emergency team calling criteria in patients admitte…
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psnet.ahrq.gov/issue/resolving-malpractice-claims-after-tort-reform-experience-self-insured-texas-public-academic
December 19, 2018 - Study
Resolving malpractice claims after tort reform: experience in a self-insured Texas public academic health system.
Citation Text:
Sage WM, Harding MC, Thomas EJ. Resolving Malpractice Claims after Tort Reform: Experience in a Self-Insured Texas Public Academic Health System. Health …
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psnet.ahrq.gov/issue/mortality-and-morbidity-meetings-untapped-resource-improving-governance-patient-safety
June 25, 2014 - Study
Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety?
Citation Text:
Higginson J, Walters R, Fulop NJ. Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety? BMJ Qual Saf. 2012;21(7):…
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psnet.ahrq.gov/issue/assessing-impact-new-pediatric-healthcare-facility-medication-administration-human-factors
February 07, 2024 - Study
Assessing the impact of a new pediatric healthcare facility on medication administration: a human factors approach.
Citation Text:
Godin MR, Nasr AS. Assessing the impact of a new pediatric healthcare facility on medication administration: a human factors approach. J Nurs Adm. 2023…
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psnet.ahrq.gov/issue/classification-health-information-technology-safety-events-pediatric-tertiary-care-hospital
May 20, 2019 - Study
Classification of health information technology safety events in a pediatric tertiary care hospital.
Citation Text:
Khan A, Karavite DJ, Muthu N, et al. Classification of health information technology safety events in a pediatric tertiary care hospital. J Patient Saf. 2023;19(4):25…
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psnet.ahrq.gov/issue/what-does-safety-commitment-mean-leaders-multi-method-investigation
September 11, 2024 - Study
What does safety commitment mean to leaders? A multi-method investigation.
Citation Text:
Fruhen LS, Griffin MA, Andrei DM. What does safety commitment mean to leaders? A multi-method investigation. J Safety Res. 2019;68:203-214. doi:10.1016/j.jsr.2018.12.011.
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psnet.ahrq.gov/issue/call-bridge-across-silos-during-care-transitions
November 20, 2024 - Commentary
A call to bridge across silos during care transitions.
Citation Text:
Sheikh F, Gathecha E, Bellantoni M, et al. A Call to Bridge Across Silos during Care Transitions. Jt Comm J Qual Patient Saf. 2018;44(5):270-278. doi:10.1016/j.jcjq.2017.10.006.
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psnet.ahrq.gov/issue/reducing-cardiopulmonary-arrest-rates-three-year-regional-rapid-response-system-collaborative
March 04, 2011 - Study
Reducing cardiopulmonary arrest rates in a three-year regional rapid response system collaborative.
Citation Text:
Rosen MJ, Hoberman AJ, Ruiz RE, et al. Reducing cardiopulmonary arrest rates in a three-year regional rapid response system collaborative. Jt Comm J Qual Patient Saf…
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psnet.ahrq.gov/issue/extent-diagnostic-agreement-among-medical-referrals
October 31, 2011 - Study
Extent of diagnostic agreement among medical referrals.
Citation Text:
Van Such M, Lohr R, Beckman T, et al. Extent of diagnostic agreement among medical referrals. J Eval Clin Pract. 2017;23(4):870-874. doi:10.1111/jep.12747.
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psnet.ahrq.gov/issue/preventing-diagnostic-errors-ambulatory-care-electronic-notification-tool-incomplete
April 22, 2013 - Study
Preventing diagnostic errors in ambulatory care: an electronic notification tool for incomplete radiology tests.
Citation Text:
Weingart SN, Yaghi O, Barnhart L, et al. Preventing diagnostic errors in ambulatory care: an electronic notification tool for incomplete radiology tests. …
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psnet.ahrq.gov/issue/automated-communication-tools-and-computer-based-medication-reconciliation-decrease-hospital
September 23, 2020 - Study
Automated communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors.
Citation Text:
Smith KJ, Handler S, Kapoor WN, et al. Automated Communication Tools and Computer-Based Medication Reconciliation to Decrease Hospital Dischar…
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psnet.ahrq.gov/issue/patient-provider-and-system-factors-contributing-patient-safety-events-during-medical-and
November 18, 2016 - Study
Patient, provider, and system factors contributing to patient safety events during medical and surgical hospitalizations for persons with serious mental illness.
Citation Text:
McGinty EE, Thompson DA, Pronovost P, et al. Patient, provider, and system factors contributing to patien…
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psnet.ahrq.gov/issue/effect-using-same-vs-different-order-second-readings-screening-mammograms-rates-breast-cancer
August 29, 2018 - Study
Effect of using the same vs different order for second readings of screening mammograms on rates of breast cancer detection: a randomized clinical trial.
Citation Text:
Taylor-Phillips S, Wallis MG, Jenkinson D, et al. Effect of Using the Same vs Different Order for Second Readings…
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psnet.ahrq.gov/node/37152/psn-pdf
September 05, 2007 - Why pay for mistakes?
September 5, 2007
https://psnet.ahrq.gov/issue/why-pay-mistakes
Recently, CMS ruled that Medicare will no longer cover certain preventable errors. In this op-ed piece, the
author discusses why this new rule will drive hospitals to implement safety measures.
https://psnet.ahrq.gov/issue/why-pa…
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psnet.ahrq.gov/node/33938/psn-pdf
December 18, 2008 - Dana-Farber Cancer Institute Principles of a Fair and Just
Culture.
December 18, 2008
Dana-Farber Cancer Institute.
https://psnet.ahrq.gov/issue/dana-farber-cancer-institute-principles-fair-and-just-culture
Dana-Farber Cancer Institute defines a "just culture" and illustrates how to implement and sustain it.
http…