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psnet.ahrq.gov/issue/childrens-hospital-investigated-five-patient-deaths-deadly-fungal-disease-2009
June 14, 2017 - Newspaper/Magazine Article
Children's Hospital investigated five patient deaths from deadly fungal disease in 2009.
Citation Text:
Duffy J, Harris J, Gade L, et al. Mucormycosis outbreak associated with hospital linens. The Pediatric infectious disease journal. 2014;33(5):472-6. doi:10.1…
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psnet.ahrq.gov/issue/impact-adverse-events-prescribing-warfarin-patients-atrial-fibrillation-matched-pair-analysis
August 15, 2018 - Study
Impact of adverse events on prescribing warfarin in patients with atrial fibrillation: matched pair analysis.
Citation Text:
Choudhry NK, Anderson G, Laupacis A, et al. Impact of adverse events on prescribing warfarin in patients with atrial fibrillation: matched pair analysis. B…
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psnet.ahrq.gov/issue/enhancing-pediatric-perioperative-patient-safety
January 28, 2015 - Commentary
Enhancing pediatric perioperative patient safety.
Citation Text:
Johnson Q, McVey J. Enhancing Pediatric Perioperative Patient Safety. AORN J. 2017;106(5):434-442. doi:10.1016/j.aorn.2017.09.007.
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psnet.ahrq.gov/issue/will-human-factors-restore-faith-gmc
January 12, 2022 - Commentary
Will human factors restore faith in the GMC?
Citation Text:
Morgan L, Benson D, McCulloch P. Will human factors restore faith in the GMC? BMJ. 2019;364:l1037. doi:10.1136/bmj.l1037.
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psnet.ahrq.gov/issue/state-science-evolving-perspectives-human-error
February 22, 2023 - Commentary
State of science: evolving perspectives on ‘human error’.
Citation Text:
Read GJM, Shorrock S, Walker GH, et al. State of science: evolving perspectives on ‘human error’. Ergonomics. 2021;64(9):1091-1114. doi:10.1080/00140139.2021.1953615.
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psnet.ahrq.gov/issue/whats-difference-between-hospital-and-bottling-factory
October 08, 2008 - Commentary
What's the difference between a hospital and a bottling factory?
Citation Text:
Morton A, Cornwell J. What's the difference between a hospital and a bottling factory? BMJ. 2009;339(jul20 1). doi:10.1136/bmj.b2727.
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psnet.ahrq.gov/issue/parenteral-opioid-shortage-treating-pain-during-opioid-overdose-epidemic
January 31, 2024 - Commentary
Emerging Classic
Parenteral opioid shortage—treating pain during the opioid-overdose epidemic.
Citation Text:
Bruera E. Parenteral Opioid Shortage - Treating Pain during the Opioid-Overdose Epidemic. N Engl J Med. 2018;379(7):601-603. doi:10.1056/NEJM…
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psnet.ahrq.gov/issue/when-medical-care-leads-harm-difficulty-finding-words-teachable-moment
September 23, 2017 - Commentary
When medical care leads to harm—difficulty finding words: a teachable moment.
Citation Text:
Chamberlain E, DiVeronica M, Segura R. When medical care leads to harm- difficulty finding words: a teachable moment. JAMA Intern Med. 2015;175(8):1271-1272. doi:10.1001/jamainternmed.…
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psnet.ahrq.gov/issue/impact-electronic-health-record-systems-information-integrity-quality-and-safety-implications
April 03, 2024 - Review
Impact of electronic health record systems on information integrity: quality and safety implications.
Citation Text:
Bowman S. Impact of electronic health record systems on information integrity: quality and safety implications. Perspect Health Inf Manag. 2013;10:1c.
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psnet.ahrq.gov/issue/quality-performance-improvement-teamwork-information-technology-and-protocols
November 03, 2015 - Commentary
Quality: performance improvement, teamwork, information technology and protocols.
Citation Text:
Coleman NE, Pon S. Quality: performance improvement, teamwork, information technology and protocols. Crit Care Clin. 2013;29(2):129-51. doi:10.1016/j.ccc.2012.11.002.
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psnet.ahrq.gov/issue/novel-tool-organisational-learning-and-its-impact-safety-culture-hospital-dispensary
January 21, 2015 - Study
A novel tool for organisational learning and its impact on safety culture in a hospital dispensary.
Citation Text:
Sujan MA. A novel tool for organisational learning and its impact on safety culture in a hospital dispensary. Reliab Eng Syst Saf. 2012;101:21-34. doi:10.1016/j.ress…
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psnet.ahrq.gov/issue/acute-care-patients-discuss-patient-role-patient-safety
October 12, 2011 - Study
Acute care patients discuss the patient role in patient safety.
Citation Text:
Rathert C, Huddleston N, Pak Y. Acute care patients discuss the patient role in patient safety. Health Care Manage Rev. 2011;36(2):134-144. doi:10.1097/HMR.0b013e318208cd31.
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psnet.ahrq.gov/issue/attitudes-toward-medical-device-use-errors-and-prevention-adverse-events
September 24, 2016 - Study
Attitudes toward medical device use errors and the prevention of adverse events.
Citation Text:
Johnson TR, Tang X, Graham MJ, et al. Attitudes toward medical device use errors and the prevention of adverse events. Jt Comm J Qual Patient Saf. 2007;33(11):689-94.
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psnet.ahrq.gov/issue/disclosing-harmful-pathology-errors-patients
May 18, 2022 - Commentary
Disclosing harmful pathology errors to patients.
Citation Text:
Dintzis SM, Gallagher TH. Disclosing harmful pathology errors to patients. Am J Clin Pathol. 2009;131(4):463-5. doi:10.1309/AJCPIO5SHDOD6URI.
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psnet.ahrq.gov/issue/hospital-doctors-workflow-interruptions-and-activities-observation-study
March 06, 2013 - Study
Hospital doctors' workflow interruptions and activities: an observation study.
Citation Text:
Weigl M, Müller A, Zupanc A, et al. Hospital doctors' workflow interruptions and activities: an observation study. BMJ Qual Saf. 2011;20(6):491-7. doi:10.1136/bmjqs.2010.043281.
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psnet.ahrq.gov/issue/advances-prevention-and-control-hais
August 20, 2018 - Book/Report
Advances in the Prevention and Control of HAIs.
Citation Text:
Advances in the Prevention and Control of HAIs. Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. AHRQ Publication No. 14-0003.
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psnet.ahrq.gov/issue/policies-promote-shared-responsibility-safer-electronic-health-records
August 25, 2021 - Commentary
Policies to promote shared responsibility for safer electronic health records.
Citation Text:
Sittig DF, Singh H. Policies to promote shared responsibility for safer electronic health records. JAMA. 2021;326(15):1477-1478. doi:10.1001/jama.2021.13945.
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psnet.ahrq.gov/issue/diagnostic-reasoning-and-cognitive-biases-nurse-practitioners
October 19, 2022 - Review
Diagnostic reasoning and cognitive biases of nurse practitioners.
Citation Text:
Lawson TN. Diagnostic Reasoning and Cognitive Biases of Nurse Practitioners. J Nurs Educ. 2018;57(4):203-208. doi:10.3928/01484834-20180322-03.
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psnet.ahrq.gov/issue/patient-safety-adoption-framework-practical-framework-bridge-know-do-gap
May 26, 2021 - Commentary
The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap.
Citation Text:
The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap. Moyal-Smith R, Margo J, Maloney FL, et al. J Patient Saf. 2023;19(4):243-248.
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psnet.ahrq.gov/issue/human-factors-healthcare-welcome-progress-still-scratching-surface
June 16, 2021 - Commentary
Human factors in healthcare: welcome progress, but still scratching the surface.
Citation Text:
Waterson P, Catchpole K. Human factors in healthcare: welcome progress, but still scratching the surface. BMJ Qual Saf. 2016;25(7):480-4. doi:10.1136/bmjqs-2015-005074.
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