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  1. Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk. | PSNet

    psnet.ahrq.gov/issue/improving-handoff-communications-critical-care-utilizing-simulation-based-training-toward
    February 16, 2011 - Study Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk. Citation Text: Berkenstadt H, Haviv Y, Tuval A, et al. Improving handoff communications in critical care: utilizing simulation-based training …

  2. Hospira issues a voluntary nationwide recall for one lot of 0.5% Bupivacaine Hydrochloride Injection, USP and one lot of 1% Lidocaine HCl Injection, USP due to mislabeling. | PSNet

    psnet.ahrq.gov/issue/hospira-issues-voluntary-nationwide-recall-one-lot-05-bupivacaine-hydrochloride-injection-usp
    June 20, 2018 - Press Release/Announcement Hospira issues a voluntary nationwide recall for one lot of 0.5% Bupivacaine Hydrochloride Injection, USP and one lot of 1% Lidocaine HCl Injection, USP due to mislabeling. Citation Text: Hospira issues a voluntary nationwide recall for one lot of 0.5% Bupivaca…

  3. Contextual information influences diagnosis accuracy and decision making in simulated emergency medicine emergencies. | PSNet

    psnet.ahrq.gov/issue/contextual-information-influences-diagnosis-accuracy-and-decision-making-simulated-emergency
    April 19, 2013 - Study Contextual information influences diagnosis accuracy and decision making in simulated emergency medicine emergencies. Citation Text: McRobert AP, Causer J, Vassiliadis J, et al. Contextual information influences diagnosis accuracy and decision making in simulated emergency medicin…

  4. A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. | PSNet

    psnet.ahrq.gov/issue/perfect-storm-averted-flawed-systems-dropped-ball-and-cognitive-biases-delay-critical
    November 30, 2022 - Commentary A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. Citation Text: Roberts TJ, Sellars MC, Sands JM, et al. A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. JCO Oncol…

  5. Using system analysis to build a safety culture: improving the reliability of epidural analgesia. | PSNet

    psnet.ahrq.gov/issue/using-system-analysis-build-safety-culture-improving-reliability-epidural-analgesia
    January 14, 2009 - Study Using system analysis to build a safety culture: improving the reliability of epidural analgesia. Citation Text: Garnerin P, Huchet-Belouard A, Diby M, et al. Using system analysis to build a safety culture: improving the reliability of epidural analgesia. Acta Anaesthesiol Scand…

  6. An integrative review of patient safety in studies on the care and safety of patients with communication disabilities in hospital. | PSNet

    psnet.ahrq.gov/issue/integrative-review-patient-safety-studies-care-and-safety-patients-communication-disabilities
    April 10, 2019 - Review An integrative review of patient safety in studies on the care and safety of patients with communication disabilities in hospital. Citation Text: Hemsley B, Georgiou A, Hill S, et al. An integrative review of patient safety in studies on the care and safety of patients with commun…

  7. Evaluating implementation of a rapid response team: considering alternative outcome measures. | PSNet

    psnet.ahrq.gov/issue/evaluating-implementation-rapid-response-team-considering-alternative-outcome-measures
    October 19, 2022 - Study Evaluating implementation of a rapid response team: considering alternative outcome measures. Citation Text: Moriarty JP, Schiebel NE, Johnson MG, et al. Evaluating implementation of a rapid response team: considering alternative outcome measures. Int J Qual Health Care. 2014;26(1)…

  8. A preliminary taxonomy of medical errors in family practice. | PSNet

    psnet.ahrq.gov/issue/preliminary-taxonomy-medical-errors-family-practice
    April 08, 2011 - Study Classic A preliminary taxonomy of medical errors in family practice. Citation Text: Dovey S, Meyers DS, Phillips RL, et al. A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care. 2002;11(3):233-8. Copy Citation Format: …

  9. How informatics nurses use bar code technology to reduce medication errors. | PSNet

    psnet.ahrq.gov/issue/how-informatics-nurses-use-bar-code-technology-reduce-medication-errors
    August 04, 2021 - Commentary How informatics nurses use bar code technology to reduce medication errors. Citation Text: Gann M. How informatics nurses use bar code technology to reduce medication errors. Nursing (Brux). 2015;45(3):60-6. doi:10.1097/01.NURSE.0000458923.18468.37. Copy Citation Format:…

  10. The problem with preventable deaths. | PSNet

    psnet.ahrq.gov/issue/problem-preventable-deaths
    July 24, 2024 - Commentary The problem with preventable deaths. Citation Text: Hogan H. The problem with preventable deaths. BMJ Qual Saf. 2016;25(5):320-3. doi:10.1136/bmjqs-2015-004983. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…

  11. Identification by families of pediatric adverse events and near misses overlooked by health care providers. | PSNet

    psnet.ahrq.gov/issue/identification-families-pediatric-adverse-events-and-near-misses-overlooked-health-care
    November 23, 2016 - Study Identification by families of pediatric adverse events and near misses overlooked by health care providers. Citation Text: Daniels JP, Hunc K, Cochrane D, et al. Identification by families of pediatric adverse events and near misses overlooked by health care providers. CMAJ. 2012…

  12. Matching identifiers in electronic health records: implications for duplicate records and patient safety. | PSNet

    psnet.ahrq.gov/issue/matching-identifiers-electronic-health-records-implications-duplicate-records-and-patient
    October 13, 2015 - Study Matching identifiers in electronic health records: implications for duplicate records and patient safety. Citation Text: McCoy AB, Wright A, Kahn MG, et al. Matching identifiers in electronic health records: implications for duplicate records and patient safety. BMJ Qual Saf. 20…

  13. Supporting perioperative safety during a disaster through clinical crisis education. | PSNet

    psnet.ahrq.gov/issue/supporting-perioperative-safety-during-disaster-through-clinical-crisis-education
    July 05, 2017 - Commentary Supporting perioperative safety during a disaster through clinical crisis education. Citation Text: Kirkman A, Tripp H, Ward L, et al. Supporting perioperative safety during a disaster through clinical crisis education. AORN J. 2024;120(4):226-237. doi:10.1002/aorn.14217. Co…

  14. A theoretical framework and competency-based approach to improving handoffs. | PSNet

    psnet.ahrq.gov/issue/theoretical-framework-and-competency-based-approach-improving-handoffs
    March 28, 2011 - Commentary A theoretical framework and competency-based approach to improving handoffs. Citation Text: Arora VM, Johnson JK, Meltzer DO, et al. A theoretical framework and competency-based approach to improving handoffs. Qual Saf Health Care. 2008;17(1):11-4. doi:10.1136/qshc.2006.0189…

  15. The influence of formulation and medicine delivery system on medication administration errors in care homes for older people. | PSNet

    psnet.ahrq.gov/issue/influence-formulation-and-medicine-delivery-system-medication-administration-errors-care
    March 23, 2011 - Study The influence of formulation and medicine delivery system on medication administration errors in care homes for older people. Citation Text: Alldred DP, Standage C, Fletcher O, et al. The influence of formulation and medicine delivery system on medication administration errors in…

  16. The nature and occurrence of registration errors in the emergency department. | PSNet

    psnet.ahrq.gov/issue/nature-and-occurrence-registration-errors-emergency-department
    September 28, 2016 - Study The nature and occurrence of registration errors in the emergency department. Citation Text: Hakimzada AF, Green RA, Sayan OR, et al. The nature and occurrence of registration errors in the emergency department. Int J Med Inform. 2007;77(3). doi:10.1016/j.ijmedinf.2007.04.011. …

  17. Prioritising the prevention of medication handling errors. | PSNet

    psnet.ahrq.gov/issue/prioritising-prevention-medication-handling-errors
    October 22, 2008 - Study Prioritising the prevention of medication handling errors. Citation Text: Bertsche T, Niemann D, Mayer Y, et al. Prioritising the prevention of medication handling errors. Pharm World Sci. 2008;30(6):907-15. doi:10.1007/s11096-008-9250-3. Copy Citation Format: DOI…

  18. Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children. | PSNet

    psnet.ahrq.gov/issue/drug-formulations-require-potentially-inaccurate-volumes-prepare-doses-infants-and-children
    April 22, 2011 - Study Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children. Citation Text: Uppal N, Yasseen B, Seto W, et al. Drug formulations that require less than 0.1 mL of stock solution to prepare doses for infants and children. CMAJ. 2011;183(4…

  19. The influence of the availability heuristic on physicians in the emergency department. | PSNet

    psnet.ahrq.gov/issue/influence-availability-heuristic-physicians-emergency-department
    September 30, 2020 - Study The influence of the availability heuristic on physicians in the emergency department. Citation Text: Ly DP. The influence of the availability heuristic on physicians in the emergency department. Ann Emerg Med. 2021;78(5):650-657. doi:10.1016/j.annemergmed.2021.06.012. Copy Citat…

  20. Interventions to improve hand hygiene compliance in patient care. | PSNet

    psnet.ahrq.gov/issue/interventions-improve-hand-hygiene-compliance-patient-care
    September 09, 2020 - Review Interventions to improve hand hygiene compliance in patient care. Citation Text: Gould DJ, Moralejo D, Drey N, et al. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev. 2017;9(9):CD005186. doi:10.1002/14651858.cd005186.pub4. Copy Citat…
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