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psnet.ahrq.gov/issue/plans-are-worthless-planning-everything-advancing-patient-safety-better-managing-paradox
September 23, 2020 - Commentary
"Plans are worthless, but planning is everything": advancing patient safety by better managing the paradox of planning versus adaptation.
Citation Text:
Call RC, Espiritu SG, Barrows DA. “Plans are worthless, but planning is everything”: advancing patient safety by better mana…
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psnet.ahrq.gov/issue/safe-administration-medication-school-policy-statement
May 31, 2023 - Organizational Policy/Guidelines
Safe Administration of Medication in School: Policy Statement.
Citation Text:
Miotto MB, Balchan B, Combe L, et al. Safe Administration of Medication in School: Policy Statement. Pediatrics. 2024;153(6):2024066839. doi:10.1542/peds.2024-066839.
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psnet.ahrq.gov/issue/using-trainee-failures-enhance-learning-qualitative-study-pediatric-hospitalists-allowing
December 14, 2022 - Study
Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing failure.
Citation Text:
Klasen JM, Beck J, Randall CL, et al. Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing failure. Acad Pe…
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psnet.ahrq.gov/issue/operational-measurement-diagnostic-safety-state-science-0
September 28, 2022 - Commentary
Emerging Classic
Operational measurement of diagnostic safety: state of the science.
Citation Text:
Singh H, Bradford A, Goeschel CA. Operational measurement of diagnostic safety: state of the science. Diagnosis (Berl). 2021;8(1):51-66. doi:10.1515/dx…
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psnet.ahrq.gov/issue/governing-quality-and-safety-healthcare-conceptual-framework
September 03, 2011 - Commentary
Governing the quality and safety of healthcare: a conceptual framework.
Citation Text:
Brown A, Dickinson H, Kelaher M. Governing the quality and safety of healthcare: A conceptual framework. Soc Sci Med. 2018;202:99-107. doi:10.1016/j.socscimed.2018.02.020.
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psnet.ahrq.gov/issue/rapid-response-systems-systematic-review-and-meta-analysis
January 29, 2018 - Review
Rapid response systems: a systematic review and meta-analysis.
Citation Text:
Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care. 2015;19(1). doi:10.1186/s13054-015-0973-y.
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psnet.ahrq.gov/issue/development-patient-safety-measures-identify-inappropriate-diagnosis-common-infections
April 10, 2024 - Study
Development of patient safety measures to identify inappropriate diagnosis of common infections.
Citation Text:
White AT, Vaughn VM, Petty LA, et al. Development of patient safety measures to identify inappropriate diagnosis of common infections. Clin Infect Dis. 2024;78(6):1403-14…
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psnet.ahrq.gov/issue/large-language-models-preventing-medication-direction-errors-online-pharmacies
February 27, 2019 - Study
Large language models for preventing medication direction errors in online pharmacies.
Citation Text:
Pais C, Liu J, Voigt R, et al. Large language models for preventing medication direction errors in online pharmacies. Nat Med. 2024;30(6):1574-1582. doi:10.1038/s41591-024-02933-8.…
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psnet.ahrq.gov/issue/teamstepps-evidence-based-approach-reduce-clinical-errors-threatening-safety-outpatient
November 18, 2009 - Review
TeamSTEPPS: an evidence-based approach to reduce clinical errors threatening safety in outpatient settings: an integrative review.
Citation Text:
Parker AL, Forsythe LL, Kohlmorgen IK. TeamSTEPPS : An evidence-based approach to reduce clinical errors threatening safety in outpatie…
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psnet.ahrq.gov/issue/understanding-procedural-violations-using-safety-i-and-safety-ii-case-community-pharmacies
February 06, 2019 - Study
Understanding procedural violations using Safety-I and Safety-II: the case of community pharmacies.
Citation Text:
Jones CEL, Phipps D, Ashcroft DM. Understanding procedural violations using Safety-I and Safety-II: The case of community pharmacies. Saf Sci. 2018;105:114-120. doi:10…
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psnet.ahrq.gov/issue/decision-support-sensible-dosing-electronic-prescribing-systems
February 23, 2011 - Study
Decision support for sensible dosing in electronic prescribing systems.
Citation Text:
Coleman JJ, Nwulu U, Ferner RE. Decision support for sensible dosing in electronic prescribing systems. J Clin Pharm Ther. 2012;37(4):415-9. doi:10.1111/j.1365-2710.2011.01310.x.
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psnet.ahrq.gov/issue/optimal-preoperative-assessment-geriatric-surgical-patient-best-practices-guideline-american
July 13, 2010 - Commentary
Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society.
Citation Text:
Chow WB, Rosenthal RA, Merkow RP, et al. Optim…
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psnet.ahrq.gov/issue/adverse-drug-events-general-practice-patients-australia
March 04, 2020 - Study
Adverse drug events in general practice patients in Australia.
Citation Text:
Miller GC, Britth HC, Valenti L. Adverse drug events in general practice patients in Australia. Med J Aust. 2006;184(7):321-4.
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psnet.ahrq.gov/issue/mislabeled-units-umbilical-cord-blood-detected-quality-assurance-program-transplantation
October 19, 2022 - Study
Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center.
Citation Text:
McCullough JS, McKenna D, Kadidlo D, et al. Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation cente…
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psnet.ahrq.gov/issue/epidemiology-and-risk-factors-harmful-anti-infective-medication-errors-pediatric-hospital
March 22, 2017 - Study
Epidemiology of and risk factors for harmful anti-infective medication errors in a pediatric hospital.
Citation Text:
Modi A, Germain E, Soma V, et al. Epidemiology of and Risk Factors for Harmful Anti-Infective Medication Errors in a Pediatric Hospital. Jt Comm J Qual Patient Saf.…
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psnet.ahrq.gov/issue/comprehensive-analysis-medication-dosing-error-related-cpoe
June 01, 2005 - Commentary
Comprehensive analysis of a medication dosing error related to CPOE.
Citation Text:
Horsky J, Kuperman GJ, Patel VL. Comprehensive Analysis of a Medication Dosing Error Related to CPOE: Table 1. J Am Med Info Assoc. 2005;12(4). doi:10.1197/jamia.m1740.
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psnet.ahrq.gov/issue/hospital-medication-errors-cross-sectional-study
September 30, 2020 - Study
Hospital medication errors: a cross sectional study.
Citation Text:
ISAACS AN, Ch'ng K, DELHIWALE N, et al. Hospital medication errors: a cross-sectional study. Int J Qual Health Care. 2021;33(1):mzaa136. doi:10.1093/intqhc/mzaa136.
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psnet.ahrq.gov/issue/effect-crew-resource-management-diabetes-care-and-patient-outcomes-inner-city-primary-care
November 24, 2010 - Study
Effect of crew resource management on diabetes care and patient outcomes in an inner-city primary care clinic.
Citation Text:
Taylor CR, Hepworth JT, Buerhaus P, et al. Effect of crew resource management on diabetes care and patient outcomes in an inner-city primary care clinic. …
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psnet.ahrq.gov/issue/longitudinal-evaluation-programme-safety-culture-change-mental-health-service
January 24, 2018 - Study
Longitudinal evaluation of a programme for safety culture change in a mental health service.
Citation Text:
Dickens GL, Salamonson Y, Johnson A, et al. Longitudinal evaluation of a programme for safety culture change in a mental health service. J Nurs Manag. 2021;29(4):690-698. doi…
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psnet.ahrq.gov/issue/striving-zero-error-patient-surgical-journey-through-adoption-aviation-style-challenge-and
July 10, 2017 - Study
Striving for a zero-error patient surgical journey through adoption of aviation-style challenge and response flow checklists: a quality improvement project.
Citation Text:
Low DK, Reed MA, Geiduschek JM, et al. Striving for a zero-error patient surgical journey through adoption …