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psnet.ahrq.gov/issue/2022-john-m-eisenberg-patient-safety-and-quality-awards
August 02, 2023 - Special or Theme Issue
2022 John M. Eisenberg Patient Safety and Quality Awards.
Citation Text:
2022 John M. Eisenberg Patient Safety and Quality Awards. Jt Comm J Qual Patient Saf. 2023;49(9):435-450.
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psnet.ahrq.gov/issue/recognizing-importance-whistleblowers-healthcare
June 24, 2009 - Commentary
Recognizing the importance of whistleblowers in healthcare.
Citation Text:
O'Neill N. Recognizing the importance of whistleblowers in healthcare. Nursing (Brux). 2021;51(4):54-56. doi:10.1097/01.nurse.0000736912.14380.65.
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psnet.ahrq.gov/issue/medicines-related-harm-elderly-post-hospital-discharge
February 07, 2024 - Commentary
Medicines-related harm in the elderly post-hospital discharge.
Citation Text:
Medicines-related harm in the elderly post-hospital discharge. Cheong V-L, Tomlinson J, Khan S, et al. Prescriber. 2019;30:29-34.
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psnet.ahrq.gov/issue/performing-wrong-procedure
April 24, 2018 - Commentary
Performing the wrong procedure.
Citation Text:
Minnier T, Phrampus P, Waddell L. Performing the Wrong Procedure. JAMA. 2016;316(11):1207-1208. doi:10.1001/jama.2016.9134.
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psnet.ahrq.gov/issue/medication-errors-older-people-mental-health-problems-review
April 27, 2022 - Review
Medication errors in older people with mental health problems: a review.
Citation Text:
doi:10.1002/gps.1943.
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psnet.ahrq.gov/issue/surgical-never-events-how-common-are-adverse-occurrences
November 16, 2022 - Commentary
Surgical 'never events': how common are adverse occurrences?
Citation Text:
West JC. Surgical ‘never events’: How common are adverse occurrences? Journal of Healthcare Risk Management. 2009;26(1). doi:10.1002/jhrm.5600260105.
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psnet.ahrq.gov/issue/interception-potential-adverse-drug-events-long-term-psychiatric-care-units
May 31, 2023 - Study
Interception of potential adverse drug events in long-term psychiatric care units.
Citation Text:
Sawamura K, Ito H, Yamazumi S, et al. Interception of potential adverse drug events in long-term psychiatric care units. Psychiatry Clin Neurosci. 2005;59(4):379-84.
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psnet.ahrq.gov/issue/subtherapeutic-heparin-infusions-your-organization-risk-bypassing-soft-low-dose-alerts
November 18, 2020 - Newspaper/Magazine Article
Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts?
Citation Text:
Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts? ISMP Medication Safety Alert! Acute Care Edition. …
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psnet.ahrq.gov/issue/patient-safety-story
February 02, 2020 - Commentary
The patient safety story.
Citation Text:
Elwyn G, Corrigan JM. The patient safety story. BMJ. 2005;331(7512):302-304. doi:10.1136/bmj.38562.690104.43.
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psnet.ahrq.gov/issue/interdisciplinary-communication-intensive-care-unit
April 18, 2011 - Study
Interdisciplinary communication in the intensive care unit.
Citation Text:
Reader TW, Flin R, Mearns K, et al. Interdisciplinary communication in the intensive care unit. Br J Anaesth. 2007;98(3):347-52.
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psnet.ahrq.gov/issue/involuntary-automaticity-work-system-induced-risk-safe-health-care
June 22, 2009 - Commentary
Involuntary automaticity: a work-system induced risk to safe health care.
Citation Text:
Toft B, Mascie-Taylor H. Involuntary automaticity: a work-system induced risk to safe health care. Health Serv Manage Res. 2005;18(4):211-6.
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psnet.ahrq.gov/issue/patient-misidentification-oncology-care
March 22, 2006 - Commentary
Patient misidentification in oncology care.
Citation Text:
Patient misidentification in oncology care. Schulmeister L. Clin J Oncol Nurs. 2008;12:495-498.
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psnet.ahrq.gov/issue/anatomy-medical-device-recall-how-defective-products-can-slip-through-outdated-system
December 03, 2014 - Newspaper/Magazine Article
Anatomy of a medical device recall: how defective products can slip through an outdated system.
Citation Text:
Anatomy of a medical device recall: how defective products can slip through an outdated system. Zipp R. Medical Tech Dive. October 18, 2021.
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psnet.ahrq.gov/issue/time-prefilled-syringes-everywhere
July 13, 2010 - Commentary
Time for prefilled syringes - everywhere.
Citation Text:
Whitaker DK, Lomas JP. Time for prefilled syringes – everywhere. Anaesthesia. 2024;79(2):119-122. doi:10.1111/anae.16181.
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psnet.ahrq.gov/issue/62-year-old-woman-skin-cancer-who-experienced-wrong-site-surgery
December 01, 2021 - Commentary
Classic
A 62-year-old woman with skin cancer who experienced wrong-site surgery.
Citation Text:
Gallagher TH. A 62-year-old woman with skin cancer who experienced wrong-site surgery: review of medical error. JAMA. 2009;302(6):669-77. doi:10.1001/jam…
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psnet.ahrq.gov/issue/11-medicine-mistakes-avoid
March 20, 2024 - Newspaper/Magazine Article
11 medicine mistakes to avoid.
Citation Text:
Crouch M. 11 medicine mistakes to avoid. AARP. August 06, 2024;
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/tool.html
June 01, 2017 - Sustainability Tool - Sustainability Module
Background: This tool can be used to identify sustainability issues in planning and implementing your improvement efforts.
How to use this tool: The Implementation Team leader (or individual designated by the leader) should complete this checklist.
Us…
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psnet.ahrq.gov/issue/guideline-prevention-unintentionally-retained-surgical-items
August 01, 2018 - Commentary
Guideline for Prevention of Unintentionally Retained Surgical Items.
Citation Text:
Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6. doi:10.1002/aorn.13579.
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psnet.ahrq.gov/issue/lessons-war-cancer-need-basic-research-safety
July 14, 2010 - Commentary
Lessons from the war on cancer: the need for basic research on safety.
Citation Text:
Lessons from the war on cancer: the need for basic research on safety. Cook RI. J Patient Saf. 2005.1(1):7-8
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psnet.ahrq.gov/issue/detecting-drug-interactions-using-personal-digital-assistants-out-patient-clinic
March 28, 2011 - Study
Detecting drug interactions using personal digital assistants in an out-patient clinic.
Citation Text:
Dallenbach F, Bovier PA, Desmeules J. Detecting drug interactions using personal digital assistants in an out-patient clinic. QJM. 2007;100(11):691-7.
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