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psnet.ahrq.gov/issue/deciphering-harm-measurement
December 01, 2010 - Commentary
Deciphering harm measurement.
Citation Text:
Parry G, Cline A, Goldmann D. Deciphering harm measurement. JAMA. 2012;307(20):2155-6. doi:10.1001/jama.2012.3649.
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psnet.ahrq.gov/issue/lost-art-doctoring-reflections-pediatric-resident
November 21, 2021 - Commentary
The lost art of doctoring: reflections of a pediatric resident.
Citation Text:
Mitchell SM. The Lost Art of Doctoring: Reflections of a Pediatric Resident. JAMA Pediatr. 2018;172(1):10. doi:10.1001/jamapediatrics.2017.3247.
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psnet.ahrq.gov/issue/changing-smart-pump-vendors-lessons-learned
August 01, 2018 - Commentary
Changing smart pump vendors: lessons learned.
Citation Text:
Arthur KJ, Catlin AC, Quebe A, et al. Changing Smart Pump Vendors: Lessons Learned. Hosp Pharm. 2016;51(9):782-789.
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psnet.ahrq.gov/issue/teamwork-and-error-operating-room-analysis-skills-and-roles
April 15, 2009 - Study
Teamwork and error in the operating room: analysis of skills and roles.
Citation Text:
Catchpole K, Mishra A, Handa A, et al. Teamwork and error in the operating room: analysis of skills and roles. Ann Surg. 2008;247(4):699-706. doi:10.1097/SLA.0b013e3181642ec8.
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psnet.ahrq.gov/issue/assessing-performance-surgical-teams
July 05, 2017 - Study
Assessing the performance of surgical teams.
Citation Text:
Leach LS, Myrtle RC, Weaver FA, et al. Assessing the performance of surgical teams. Health Care Manage Rev. 2009;34(1):29-41. doi:10.1097/01.HMR.0000342977.84307.64.
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psnet.ahrq.gov/issue/systems-approach-address-impact-second-victim-phenomenon
December 07, 2022 - Commentary
A systems approach to address the impact of second victim phenomenon.
Citation Text:
Gamble B, Gamble KJ. A systems approach to address the impact of second victim phenomenon. Health Serv Manage Res. 2022;35(2):110-113. doi:10.1177/0951484820971455.
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psnet.ahrq.gov/issue/internal-medicine-work-hours-trends-associations-and-implications-future
February 03, 2016 - Study
Internal medicine work hours: trends, associations, and implications for the future.
Citation Text:
Shiotani LM, Parkerton PH, Wenger N, et al. Internal medicine work hours: trends, associations, and implications for the future. Am J Med. 2008;121(1):80-5. doi:10.1016/j.amjmed.20…
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psnet.ahrq.gov/issue/road-zero-preventable-birth-injuries
January 05, 2012 - Commentary
The road to zero preventable birth injuries.
Citation Text:
Mazza F, Kitchens J, Akin M, et al. The road to zero preventable birth injuries. Jt Comm J Qual Patient Saf. 2008;34(4):201-205.
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psnet.ahrq.gov/issue/three-simple-rules-improve-medication-safety
March 11, 2020 - Commentary
Three simple rules to improve medication safety.
Citation Text:
Barba V. Three Simple Rules to Improve Medication Safety. J Patient Saf. 2016;12(3):171-2. doi:10.1097/PTS.0000000000000095.
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psnet.ahrq.gov/issue/lessons-learned-building-culture-patient-safety-within-veterans-health-administration
November 06, 2019 - Congressional Testimony
Lessons Learned? Building a Culture of Patient Safety Within the Veterans Health Administration.
Citation Text:
Lessons Learned? Building a Culture of Patient Safety Within the Veterans Health Administration. US House of Representatives Committee on Veterans' Affa…
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psnet.ahrq.gov/issue/family-identified-barriers-medication-reconciliation
September 01, 2018 - Study
Family-identified barriers to medication reconciliation.
Citation Text:
Riley-Lawless K. Family-identified barriers to medication reconciliation. J Spec Pediatr Nurs. 2009;14(2):94-101. doi:10.1111/j.1744-6155.2009.00182.x.
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psnet.ahrq.gov/issue/structural-iatrogenesis-43-year-old-man-opioid-misuse
September 04, 2016 - Commentary
Structural iatrogenesis—a 43-year-old man with "opioid misuse."
Citation Text:
Stonington S, Coffa D. Structural Iatrogenesis - A 43-Year-Old Man with "Opioid Misuse". N Engl J Med. 2019;380(8):701-704. doi:10.1056/NEJMp1811473.
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psnet.ahrq.gov/issue/sages-fuse-program-bridging-patient-safety-gap
April 05, 2017 - Commentary
The SAGES FUSE program: bridging a patient safety gap.
Citation Text:
Fuchshuber PR, Robinson TN, Feldman LS, et al. The SAGES FUSE program: bridging a patient safety gap. Bull Am Coll Surg. 2014;99(9):18-27.
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psnet.ahrq.gov/issue/health-literacy-and-mortality-among-elderly-persons
April 24, 2018 - Study
Health literacy and mortality among elderly persons.
Citation Text:
Baker DW, Wolf MS, Feinglass J, et al. Health literacy and mortality among elderly persons. Arch Intern Med. 2007;167(14):1503-9.
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psnet.ahrq.gov/issue/drug-shortages-complex-health-care-crisis
September 12, 2016 - Review
Drug shortages: a complex health care crisis.
Citation Text:
Fox ER, Sweet B, Jensen V. Drug shortages: a complex health care crisis. Mayo Clin Proc. 2014;89(3):361-73. doi:10.1016/j.mayocp.2013.11.014.
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psnet.ahrq.gov/issue/incorporating-quality-and-safety-values-clabsi-simulation-experience
February 14, 2017 - Commentary
Incorporating quality and safety values into a CLABSI simulation experience.
Citation Text:
Liebrecht CM, Lieb MC. Incorporating Quality and Safety Values into a CLABSI Simulation Experience. Nurs Forum. 2017;52(2):118-123. doi:10.1111/nuf.12175.
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psnet.ahrq.gov/issue/inside-closed-loop-medication-strategy-medication-management-targets-stages-which-errors
January 30, 2013 - Study
Inside a closed-loop medication strategy: medication management targets stages in which errors occur, step by step.
Citation Text:
Williams CT. Inside a closed-loop medication strategy. Nurs Manag. 2004;35 Suppl 5:8-9, 24.
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psnet.ahrq.gov/issue/pharmacist-transition-care-services-improve-patient-satisfaction-and-decrease-hospital
March 11, 2020 - Study
Pharmacist transition-of-care services improve patient satisfaction and decrease hospital readmissions.
Citation Text:
Pharmacist transition-of-care services improve patient satisfaction and decrease hospital readmissions. March KL, Peters MJ, Finch CK, et al. J Pharm Pract. 2…
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psnet.ahrq.gov/issue/implementing-computerized-physician-order-management-community-hospital
November 16, 2022 - Commentary
Implementing computerized physician order management at a community hospital.
Citation Text:
Kraus S, Barber TR, Briggs B, et al. Implementing computerized physician order management at a community hospital. Jt Comm J Qual Patient Saf. 2008;34(2):74-84.
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psnet.ahrq.gov/issue/improving-communication-between-teams-managing-boarded-patients-surgical-specialty-ward
September 29, 2017 - Commentary
Improving the communication between teams managing boarded patients on a surgical specialty ward.
Citation Text:
Puvaneswaralingam S, Ross D. Improving the communication between teams managing boarded patients on a surgical specialty ward. BMJ Qual Improv Rep. 2016;5(1). doi:1…