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psnet.ahrq.gov/issue/safely-implementing-health-information-and-converging-technologies
May 14, 2018 - Sentinel Event Alerts
Safely implementing health information and converging technologies.
Citation Text:
Safely implementing health information and converging technologies. Sentinel event alert. 2008;(42):1-4.
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psnet.ahrq.gov/issue/moving-patient-safety-ambulatory-settings-and-beyond
October 02, 2019 - Commentary
Moving patient safety into ambulatory settings and beyond.
Citation Text:
Ricciardi R, Shofer M. Moving Patient Safety Into Ambulatory Settings and Beyond. J Nurs Care Qual. 2018;33(3):195-199. doi:10.1097/NCQ.0000000000000329.
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psnet.ahrq.gov/issue/ismp-list-high-alert-medications-long-term-care-ltc-settings
December 15, 2021 - Fact Sheet/FAQs
ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings.
Citation Text:
ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings. Horsham, PA: Institute of Safe Medication Practices; 2021
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psnet.ahrq.gov/issue/avoiding-wrong-site-surgery-systematic-review
October 19, 2022 - Review
Avoiding wrong site surgery: a systematic review.
Citation Text:
Devine J, Chutkan N, Norvell DC, et al. Avoiding wrong site surgery: a systematic review. Spine (Phila Pa 1976). 2010;35(9 Suppl):S28-36. doi:10.1097/BRS.0b013e3181d833ac.
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psnet.ahrq.gov/issue/national-database-nursing-quality-indicatorstm-ndnqir
May 25, 2022 - Commentary
The National Database of Nursing Quality Indicators(TM) (NDNQI®).
Citation Text:
The National Database of Nursing Quality Indicators(TM) (NDNQI®). Montalvo I. Online J Iss Nurs. 2007;12(3):Manuscript 2.
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psnet.ahrq.gov/issue/adherence-medication-safety-protocol-current-practice-labeling-medications-and-solutions
July 19, 2023 - Study
Adherence to a medication safety protocol: current practice for labeling medications and solutions on the sterile field.
Citation Text:
Brown-Brumfield D, DeLeon A. Adherence to a medication safety protocol: current practice for labeling medications and solutions on the sterile f…
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psnet.ahrq.gov/issue/mean-girls-er-alarming-nurse-culture-bullying-and-hazing
November 01, 2017 - Newspaper/Magazine Article
Mean girls of the ER: the alarming nurse culture of bullying and hazing.
Citation Text:
Mean girls of the ER: the alarming nurse culture of bullying and hazing. Robbins A. Good Housekeeping. May 20, 2016.
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psnet.ahrq.gov/issue/toward-modelling-safety-violations-healthcare-systems
May 01, 2024 - Commentary
Toward the modelling of safety violations in healthcare systems.
Citation Text:
Catchpole K. Toward the modelling of safety violations in healthcare systems. BMJ Qual Saf. 2013;22(9):705-9. doi:10.1136/bmjqs-2012-001604.
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psnet.ahrq.gov/issue/testing-classification-model-emergency-department-errors
March 02, 2010 - Study
Testing a classification model for emergency department errors.
Citation Text:
Henneman EA, Blank FSJ, Gattasso S, et al. Testing a classification model for emergency department errors. J Adv Nurs. 2006;55(1):90-9.
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psnet.ahrq.gov/issue/emergency-department-medication-lists-are-not-accurate
March 02, 2010 - Study
Emergency department medication lists are not accurate.
Citation Text:
Caglar S, Henneman PL, Blank FS, et al. Emergency department medication lists are not accurate. J Emerg Med. 2011;40(6):613-6. doi:10.1016/j.jemermed.2008.02.060.
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psnet.ahrq.gov/issue/no-simple-fix-fixation-errors-cognitive-processes-and-their-clinical-applications
February 10, 2012 - Study
No simple fix for fixation errors: cognitive processes and their clinical applications.
Citation Text:
Fioratou E, Flin R, Glavin R. No simple fix for fixation errors: cognitive processes and their clinical applications. Anaesthesia. 2009;65(1). doi:10.1111/j.1365-2044.2009.05994…
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psnet.ahrq.gov/issue/still-hard-share-psos-making-progress-still-face-tech-hurdles
February 08, 2010 - Newspaper/Magazine Article
Still hard to share. PSOs making progress but still face tech hurdles.
Citation Text:
DerGurahian J. Still hard to share. PSOs making progress but still face tech hurdles. Modern healthcare. 2009;39(41):30, 32.
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psnet.ahrq.gov/issue/strategies-used-nurses-recover-medical-errors-academic-emergency-department-setting
September 26, 2016 - Study
Strategies used by nurses to recover medical errors in an academic emergency department setting.
Citation Text:
Henneman EA, Blank FSJ, Gawlinski A, et al. Strategies used by nurses to recover medical errors in an academic emergency department setting. Appl Nurs Res. 2006;19(2):70-…
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psnet.ahrq.gov/issue/early-warnings-weak-signals-and-learning-healthcare-disasters
February 28, 2024 - Commentary
Early warnings, weak signals and learning from healthcare disasters.
Citation Text:
Macrae C. Early warnings, weak signals and learning from healthcare disasters. BMJ Qual Saf. 2014;23(6):440-5. doi:10.1136/bmjqs-2013-002685.
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psnet.ahrq.gov/issue/health-information-technology-united-states-information-base-progress
April 04, 2018 - Book/Report
Health Information Technology in the United States: The Information Base for Progress.
Citation Text:
Health Information Technology in the United States: The Information Base for Progress. Blumenthal D, DesRoches C, Donelan K, et al. Princeton, NJ: Robert Wood Johnson F…
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psnet.ahrq.gov/issue/fdasia-health-it-report-proposed-strategy-and-recommendations-risk-based-framework
June 29, 2016 - Government Resource
FDASIA Health IT Report: Proposed Strategy and Recommendations for a Risk-Based Framework.
Citation Text:
FDASIA Health IT Report: Proposed Strategy and Recommendations for a Risk-Based Framework. Washington, DC: Office of the National Coordinator for Health Informati…
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psnet.ahrq.gov/issue/flaws-clinical-reasoning-common-cause-diagnostic-error
September 30, 2012 - Commentary
Flaws in clinical reasoning: a common cause of diagnostic error.
Citation Text:
Wellbery C. Flaws in clinical reasoning: a common cause of diagnostic error. Am Fam Physician. 2011;84(9):1042-8.
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psnet.ahrq.gov/issue/how-perioperative-nurses-define-attribute-causes-and-react-intraoperative-nursing-errors
September 11, 2024 - Study
How perioperative nurses define, attribute causes of, and react to intraoperative nursing errors.
Citation Text:
Chard R. How perioperative nurses define, attribute causes of, and react to intraoperative nursing errors. AORN J. 2010;91(1):132-45. doi:10.1016/j.aorn.2009.06.028.
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psnet.ahrq.gov/issue/emergency-department-crowding-canary-health-care-system
March 30, 2022 - Study
Emergency department crowding: the canary in the health care system.
Citation Text:
doi:10.1056/CAT.21.0217.
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psnet.ahrq.gov/node/49473/psn-pdf
March 01, 2005 - The tendency to take
shortcuts and save time is a very human one, but it also increases the risk of … Lack of predictability greatly
increases the risk of mistakes.