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psnet.ahrq.gov/issue/effects-efforts-optimise-morbidity-and-mortality-rounds-serve-contemporary-quality
July 19, 2019 - Review
Effects of efforts to optimise morbidity and mortality rounds to serve contemporary quality improvement and educational goals: a systematic review.
Citation Text:
Smaggus A, Mrkobrada M, Marson A, et al. Effects of efforts to optimise morbidity and mortality rounds to serve contem…
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psnet.ahrq.gov/issue/pharmacists-perceptions-computerized-prescriber-order-entry-systems
June 29, 2011 - Study
Pharmacists' perceptions of computerized prescriber-order-entry systems.
Citation Text:
Inquilla CC, Szeinbach S, Seoane-Vazquez E, et al. Pharmacists' perceptions of computerized prescriber-order-entry systems. Am J Health Syst Pharm. 2007;64(15):1626-32.
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psnet.ahrq.gov/issue/computerized-physician-order-entry-helpful-or-harmful
January 06, 2018 - Commentary
Classic
Computerized physician order entry: helpful or harmful?
Citation Text:
Berger RG, Kichak JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc. 2004;11(2):100-3.
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psnet.ahrq.gov/issue/evaluation-causes-and-frequency-medication-errors-during-information-technology-downtime
October 03, 2011 - Study
Evaluation of causes and frequency of medication errors during information technology downtime.
Citation Text:
Hanuscak TL, Szeinbach SL, Seoane-Vazquez E, et al. Evaluation of causes and frequency of medication errors during information technology downtime. Am J Health Syst Pharm…
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psnet.ahrq.gov/issue/patient-handover-surgery-intensive-care-using-formula-1-pit-stop-and-aviation-models-improve
October 03, 2011 - Study
Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality.
Citation Text:
Catchpole K, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to …
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psnet.ahrq.gov/issue/information-transfer-and-communication-surgery-systematic-review
September 26, 2012 - Review
Information transfer and communication in surgery: a systematic review.
Citation Text:
Nagpal K, Vats A, Lamb B, et al. Information transfer and communication in surgery: a systematic review. Ann Surg. 2010;252(2):225-39. doi:10.1097/SLA.0b013e3181e495c2.
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psnet.ahrq.gov/issue/how-often-are-potential-patient-safety-events-present-admission
January 26, 2022 - Study
Classic
How often are potential patient safety events present on admission?
Citation Text:
Houchens RL, Elixhauser A, Romano PS. How often are potential patient safety events present on admission? Jt Comm J Qual Patient Saf. 2008;34(3):154-63.
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psnet.ahrq.gov/issue/look-alikesound-alike-drugs-literature-review-causes-and-solutions
September 28, 2022 - Review
Look alike/sound alike drugs: a literature review on causes and solutions.
Citation Text:
Ciociano N, Bagnasco L. Look alike/sound alike drugs: a literature review on causes and solutions. Int J Clin Pharm. 2014;36(2):233-242. doi:10.1007/s11096-013-9885-6.
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psnet.ahrq.gov/issue/implementation-structured-hospital-wide-morbidity-and-mortality-rounds-model
January 20, 2015 - Study
Implementation of a structured hospital-wide morbidity and mortality rounds model.
Citation Text:
Kwok ESH, Calder LA, Barlow-Krelina E, et al. Implementation of a structured hospital-wide morbidity and mortality rounds model. BMJ Qual Saf. 2017;26(6):439-448. doi:10.1136/bmjqs-201…
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psnet.ahrq.gov/primer/alert-fatigue
March 15, 2025 - For example, incorporate renal function test results into the alert system so that alerts for nephrotoxic
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psnet.ahrq.gov/issue/dispensing-errors-community-pharmacy-perceived-influence-sociotechnical-factors
October 03, 2011 - Study
Dispensing errors in community pharmacy: perceived influence of sociotechnical factors.
Citation Text:
Szeinbach S, Seoane-Vazquez E, Parekh A, et al. Dispensing errors in community pharmacy: perceived influence of sociotechnical factors. Int J Qual Health Care. 2007;19(4):203-9.…
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psnet.ahrq.gov/node/49681/psn-pdf
April 01, 2013 - Several reported PN-specific cases resulted
from failure to incorporate built-in dosing limits in the … references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
Institutions should incorporate
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psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - been recommended that fall prevention interventions comprise a multicomponent approach 5 , 8-10 and incorporate … residents. 23 Designing interventions based on social and cognitive theories may help staff and residents incorporate
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psnet.ahrq.gov/innovation/let-us-twisst-plan-simulate-study-and-act
October 12, 2018 - EMERGING INNOVATIONS
Let us to the TWISST; Plan, Simulate, Study and Act.
Citation Text:
Colman N, Hebbar KB. Let us to the TWISST; Plan, Simulate, Study and Act. Pediatr Qual Saf. 2023;8(4):e664. doi:10.1097/pq9.0000000000000664.
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psnet.ahrq.gov/issue/using-machine-learning-system-identify-and-prevent-medication-prescribing-errors-clinical-and
June 05, 2018 - Study
Emerging Classic
Using a machine learning system to identify and prevent medication prescribing errors: a clinical and cost analysis evaluation.
Citation Text:
Rozenblum R, Rodriguez-Monguio R, Volk LA, et al. Using a machine learning system to identify an…
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psnet.ahrq.gov/node/60260/psn-pdf
April 22, 2020 - Joint Statement on Multiple Patients Per Ventilator.
April 22, 2020
The Anesthesia Patient Safety Foundation, Society of Critical Care Medicine, American Association for
Respiratory Care, American Society of Anesthesiologists, American Association of Critical?Care Nurses,
and American College of Chest Physicians. M…
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psnet.ahrq.gov/node/866555/psn-pdf
August 21, 2024 - Using behavioral insights to strengthen strategies for
change. Practical applications for quality improvement in
healthcare.
August 21, 2024
Johansen RLR, Tulloch S. Using behavioral insights to strengthen strategies for change. Practical
applications for quality improvement in healthcare. J Patient Saf. 2024;20(5…
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psnet.ahrq.gov/node/36185/psn-pdf
March 28, 2011 - Defining the technical skills of teamwork in surgery.
March 28, 2011
Healey A, Undre S, Vincent C. Defining the technical skills of teamwork in surgery. Qual Saf Health Care.
2006;15(4):231-4.
https://psnet.ahrq.gov/issue/defining-technical-skills-teamwork-surgery
The authors discuss a strategy for incorporating t…
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psnet.ahrq.gov/node/40003/psn-pdf
November 02, 2012 - Meeting the Joint Commission's 2013 National Patient
Safety Goals.
November 2, 2012
Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.
https://psnet.ahrq.gov/issue/meeting-joint-commissions-2013-national-patient-safety-goals
This e-book provides tips for incorporating activitie…
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psnet.ahrq.gov/node/34579/psn-pdf
August 20, 2012 - Edgeware: Insights from Complexity Science for Health
Care Leaders. Second ed.
August 20, 2012
Zimmerman B, Lindberg C, Plsek P. Irving, TX: VHA Incorporated; 2008. ISBN: 9780966782806
https://psnet.ahrq.gov/issue/edgeware-insights-complexity-science-health-care-leaders
A workbook that presents a series of self-le…