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  1. Pharmacist-managed inpatient discharge medication reconciliation: a combined onsite and telepharmacy model. | PSNet

    psnet.ahrq.gov/issue/pharmacist-managed-inpatient-discharge-medication-reconciliation-combined-onsite-and
    July 02, 2019 - Commentary Pharmacist-managed inpatient discharge medication reconciliation: a combined onsite and telepharmacy model. Citation Text: Keeys C, Kalejaiye B, Skinner M, et al. Pharmacist-managed inpatient discharge medication reconciliation: a combined onsite and telepharmacy model. Am J H…

  2. Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room. | PSNet

    psnet.ahrq.gov/issue/double-gloves-randomized-trial-evaluate-simple-strategy-reduce-contamination-operating-room
    November 09, 2015 - Study Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room. Citation Text: Birnbach DJ, Rosen LF, Fitzpatrick M, et al. Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room. …

  3. Dental patient safety in the military health system: joining medicine in the journey to high reliability. | PSNet

    psnet.ahrq.gov/issue/dental-patient-safety-military-health-system-joining-medicine-journey-high-reliability
    October 19, 2022 - Study Dental patient safety in the military health system: joining medicine in the journey to high reliability. Citation Text: Stahl JM, Mack K, Cebula S, et al. Dental Patient Safety in the Military Health System: Joining Medicine in the Journey to High Reliability. Mil Med. 2019. doi:1…

  4. Using information technology to improve the quality and safety of emergency care. | PSNet

    psnet.ahrq.gov/issue/using-information-technology-improve-quality-and-safety-emergency-care
    July 13, 2010 - Commentary Using information technology to improve the quality and safety of emergency care. Citation Text: Handel DA, Wears RL, Nathanson LA, et al. Using Information Technology to Improve the Quality and Safety of Emergency Care. Academic Emergency Medicine. 2011;18(6). doi:10.1111/j…

  5. Medication errors and response bias: the tip of the iceberg. | PSNet

    psnet.ahrq.gov/issue/medication-errors-and-response-bias-tip-iceberg
    February 07, 2024 - Study Medication errors and response bias: the tip of the iceberg. Citation Text: Bar-Oz B, Goldman M, Lahat E, et al. Medication errors and response bias: the tip of the iceberg. Isr Med Assoc J. 2008;10(11):771-4. Copy Citation Format: Google Scholar PubMed BibTeX EndN…

  6. Delirium in hospitalized older adults. | PSNet

    psnet.ahrq.gov/issue/delirium-hospitalized-older-adults
    December 15, 2008 - Commentary Delirium in hospitalized older adults. Citation Text: Marcantonio ER. Delirium in Hospitalized Older Adults. N Engl J Med. 2017;377(15):1456-1466. doi:10.1056/NEJMcp1605501. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endno…

  7. Intravenous medication safety and smart infusion systems: lessons learned and future opportunities. | PSNet

    psnet.ahrq.gov/issue/intravenous-medication-safety-and-smart-infusion-systems-lessons-learned-and-future
    January 09, 2008 - Commentary Intravenous medication safety and smart infusion systems: lessons learned and future opportunities. Citation Text: Keohane C, Hayes J, Saniuk C, et al. Intravenous medication safety and smart infusion systems: lessons learned and future opportunities. J Infus Nurs. 2005;28(5…

  8. Evaluation of parenteral nutrition errors in an era of drug shortages. | PSNet

    psnet.ahrq.gov/issue/evaluation-parenteral-nutrition-errors-era-drug-shortages
    October 02, 2013 - Study Evaluation of parenteral nutrition errors in an era of drug shortages. Citation Text: Storey MA, Weber RJ, Besco K, et al. Evaluation of Parenteral Nutrition Errors in an Era of Drug Shortages. Nutr Clin Pract. 2016;31(2):211-7. doi:10.1177/0884533615608820. Copy Citation For…

  9. The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives. | PSNet

    psnet.ahrq.gov/issue/vha-new-england-medication-error-prevention-initiative-model-long-term-improvement
    January 04, 2017 - Commentary The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives. Citation Text: Lesar TS, Anderson ER, Fields J, et al. The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives…

  10. Influence of language barriers on outcomes of hospital care for general medicine inpatients. | PSNet

    psnet.ahrq.gov/issue/influence-language-barriers-outcomes-hospital-care-general-medicine-inpatients
    May 16, 2012 - Study Influence of language barriers on outcomes of hospital care for general medicine inpatients. Citation Text: Karliner LS, Kim SE, Meltzer DO, et al. Influence of language barriers on outcomes of hospital care for general medicine inpatients. J Hosp Med. 2010;5(5):276-82. doi:10.10…

  11. Patient safety outcomes in small urban and small rural hospitals. | PSNet

    psnet.ahrq.gov/issue/patient-safety-outcomes-small-urban-and-small-rural-hospitals
    July 23, 2010 - Study Patient safety outcomes in small urban and small rural hospitals. Citation Text: Vartak S, Ward MM, Vaughn TE. Patient safety outcomes in small urban and small rural hospitals. J Rural Health. 2010;26(1):58-66. doi:10.1111/j.1748-0361.2009.00266.x. Copy Citation Format: …

  12. Reducing clinical errors in cancer education: interpreter training. | PSNet

    psnet.ahrq.gov/issue/reducing-clinical-errors-cancer-education-interpreter-training
    October 19, 2022 - Study Reducing clinical errors in cancer education: interpreter training. Citation Text: Gany FM, Gonzalez CJ, Basu G, et al. Reducing clinical errors in cancer education: interpreter training. J Cancer Educ. 2010;25(4):560-4. doi:10.1007/s13187-010-0107-9. Copy Citation Format: …

  13. Decreasing errors in pediatric continuous intravenous infusions. | PSNet

    psnet.ahrq.gov/issue/decreasing-errors-pediatric-continuous-intravenous-infusions
    January 06, 2017 - Study Decreasing errors in pediatric continuous intravenous infusions. Citation Text: Lehmann CU, Kim G, Gujral R, et al. Decreasing errors in pediatric continuous intravenous infusions. Pediatr Crit Care Med. 2006;7(3):225-30. Copy Citation Format: Google Scholar PubMed …

  14. Frequency of pediatric medication administration errors and contributing factors. | PSNet

    psnet.ahrq.gov/issue/frequency-pediatric-medication-administration-errors-and-contributing-factors
    November 16, 2022 - Study Frequency of pediatric medication administration errors and contributing factors. Citation Text: Ozkan S, Kocaman G, Ozturk C, et al. Frequency of pediatric medication administration errors and contributing factors. J Nurs Care Qual. 2011;26(2):136-43. doi:10.1097/NCQ.0b013e31820…

  15. Conscious sedation on a general ward: the MET and clinical governance. | PSNet

    psnet.ahrq.gov/issue/conscious-sedation-general-ward-met-and-clinical-governance
    January 05, 2017 - Commentary Conscious sedation on a general ward: the MET and clinical governance. Citation Text: Warrillow S, Bellomo R, Jones D. Conscious sedation on a general ward: the MET and clinical governance. Jt Comm J Qual Patient Saf. 2007;33(2):112-7, 61. Copy Citation Format: G…

  16. Pediatric medication administration errors and workflow following implementation of a bar code medication administration system. | PSNet

    psnet.ahrq.gov/issue/pediatric-medication-administration-errors-and-workflow-following-implementation-bar-code
    July 02, 2019 - Study Pediatric medication administration errors and workflow following implementation of a bar code medication administration system. Citation Text: Hardmeier A, Tsourounis C, Moore M, et al. Pediatric medication administration errors and workflow following implementation of a bar code …

  17. ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. | PSNet

    psnet.ahrq.gov/issue/ashp-guidelines-preventing-medication-errors-chemotherapy-and-biotherapy
    September 07, 2016 - Organizational Policy/Guidelines ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. Citation Text: Goldspiel B, Hoffman JM, Griffith NL, et al. ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. Am J Health Syst Pharm. 2015;72…

  18. Full disclosure of adverse events to patients and families in the ICU: wouldn't you want to know? | PSNet

    psnet.ahrq.gov/issue/full-disclosure-adverse-events-patients-and-families-icu-wouldnt-you-want-know
    May 26, 2021 - Commentary Full disclosure of adverse events to patients and families in the ICU: wouldn't you want to know? Citation Text: Doucette E, Fazio S, LaSalle V, et al. Full disclosure of adverse events to patients and families in the ICU: wouldn't you want to know? Dynamics. 2010;21(3):16-9. …

  19. Missed steps in the preanesthetic set-up. | PSNet

    psnet.ahrq.gov/issue/missed-steps-preanesthetic-set
    June 26, 2019 - Study Missed steps in the preanesthetic set-up. Citation Text: DeMaria S, Blasius K, Neustein SM. Missed steps in the preanesthetic set-up. Anesth Analg. 2011;113(1):84-8. doi:10.1213/ANE.0b013e318219645e. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 …

  20. Strategy 4: IDEA Discharge Planning (Tool 3) (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.pdf
    January 01, 2010 - Strategy 4: IDEA Discharge Planning (Tool 3) Guide to Patient and Family Engagement :: 1 Improving Discharge Outcomes with Patients and Families Evidence for engaging patients and families in discharge planning Nearly 20 percent of patients experience an adverse event within 30 days of discharge.1,2 Re…
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