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  1. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. | PSNet

    psnet.ahrq.gov/issue/diagnostic-blood-loss-phlebotomy-and-hospital-acquired-anemia-during-acute-myocardial
    March 14, 2022 - Study Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Citation Text: Salisbury AC, Reid KJ, Alexander KP, et al. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med…

  2. Why do nurses miss nursing care? A qualitative meta-synthesis. | PSNet

    psnet.ahrq.gov/issue/why-do-nurses-miss-nursing-care-qualitative-meta-synthesis
    January 23, 2017 - Review Why do nurses miss nursing care? A qualitative meta-synthesis. Citation Text: Peng M, Saito S, Mo W, et al. Why do nurses miss nursing care? A qualitative meta‐synthesis. Jpn J Nurs Sci. 2024;21(2):e12578. doi:10.1111/jjns.12578. Copy Citation Format: DOI Google Scho…

  3. Emergency department checklist: an innovation to improve safety in emergency care. | PSNet

    psnet.ahrq.gov/issue/emergency-department-checklist-innovation-improve-safety-emergency-care
    December 20, 2023 - Commentary Emergency department checklist: an innovation to improve safety in emergency care. Citation Text: Redfern E, Hoskins R, Gray J, et al. Emergency department checklist: an innovation to improve safety in emergency care. BMJ Open Qual. 2018;7(3):e000325. doi:10.1136/bmjoq-2018-00…

  4. Reducing errors resulting from commonly missed chest radiography findings. | PSNet

    psnet.ahrq.gov/issue/reducing-errors-resulting-commonly-missed-chest-radiography-findings
    August 20, 2018 - Commentary Reducing errors resulting from commonly missed chest radiography findings. Citation Text: Gefter WB, Hatabu H. Reducing errors resulting from commonly missed chest radiography findings. Chest. 2023;163(3):634-649. doi:10.1016/j.chest.2022.12.003. Copy Citation Format: …

  5. The Institute of Medicine report on medical errors—could it do harm? | PSNet

    psnet.ahrq.gov/issue/institute-medicine-report-medical-errors-could-it-do-harm
    February 18, 2011 - Commentary Classic The Institute of Medicine report on medical errors—could it do harm? Citation Text: Brennan TA. The Institute of Medicine report on medical errors--could it do harm? N Engl J Med. 2002;342(15):1123-1125. doi:10.1056/nejm200004133421510. Co…

  6. Body CT: technical advances for improving safety. | PSNet

    psnet.ahrq.gov/issue/body-ct-technical-advances-improving-safety
    September 28, 2022 - Review Body CT: technical advances for improving safety. Citation Text: Marin D, Nelson RC, Rubin GD, et al. Body CT: technical advances for improving safety. AJR Am J Roentgenol. 2011;197(1):33-41. doi:10.2214/AJR.11.6755. Copy Citation Format: DOI Google Scholar PubMed Bi…

  7. Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system. | PSNet

    psnet.ahrq.gov/issue/prevention-wrong-location-misadministration-through-use-intradepartmental-incident-learning
    January 22, 2017 - Study Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system. Citation Text: Ford E, Smith K, Harris K, et al. Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system. M…

  8. Frequency and severity of parenteral nutrition medication errors at a large children's hospital after implementation of electronic ordering and compounding. | PSNet

    psnet.ahrq.gov/issue/frequency-and-severity-parenteral-nutrition-medication-errors-large-childrens-hospital-after
    April 11, 2011 - Study Frequency and severity of parenteral nutrition medication errors at a large children's hospital after implementation of electronic ordering and compounding. Citation Text: MacKay M, Anderson C, Boehme S, et al. Frequency and Severity of Parenteral Nutrition Medication Errors at a L…

  9. Understanding national coverage policies. Navigating the maze of HACs, serious reportable events, and wrong surgical sites. | PSNet

    psnet.ahrq.gov/issue/understanding-national-coverage-policies-navigating-maze-hacs-serious-reportable-events-and
    June 28, 2017 - Commentary Understanding national coverage policies. Navigating the maze of HACs, serious reportable events, and wrong surgical sites. Citation Text: Cook J, D'Amato C, Garrett G, et al. Understanding national coverage policies. Navigating the maze of HACs, serious reportable events, a…

  10. Association between elements of electronic health record systems and the weekend effect in urgent general surgery. | PSNet

    psnet.ahrq.gov/issue/association-between-elements-electronic-health-record-systems-and-weekend-effect-urgent
    November 04, 2015 - Study Association between elements of electronic health record systems and the weekend effect in urgent general surgery. Citation Text: Kothari A, Brownlee SA, Blackwell RH, et al. Association Between Elements of Electronic Health Record Systems and the Weekend Effect in Urgent General S…

  11. A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions. | PSNet

    psnet.ahrq.gov/issue/prospective-hazard-and-improvement-analytic-approach-predicting-effectiveness-medication
    December 04, 2013 - Study A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions. Citation Text: Karnon J, McIntosh A, Dean JE, et al. A prospective hazard and improvement analytic approach to predicting the effectiveness of medication erro…

  12. Patient safety culture in primary care: developing a theoretical framework for practical use. | PSNet

    psnet.ahrq.gov/issue/patient-safety-culture-primary-care-developing-theoretical-framework-practical-use
    September 06, 2017 - Study Patient safety culture in primary care: developing a theoretical framework for practical use. Citation Text: Kirk S, Parker D, Claridge T, et al. Patient safety culture in primary care: developing a theoretical framework for practical use. Qual Saf Health Care. 2007;16(4):313-20.…

  13. Crisis preparedness: a systems-based framework for avoiding harm in surgery. | PSNet

    psnet.ahrq.gov/issue/crisis-preparedness-systems-based-framework-avoiding-harm-surgery
    September 14, 2022 - Study Crisis preparedness: a systems-based framework for avoiding harm in surgery. Citation Text: Gogalniceanu P, Karydis N, Costan V-V, et al. Crisis preparedness: a systems-based framework for avoiding harm in surgery. J Am Coll Surg. 2022;235(4):612-623. doi:10.1097/xcs.00000000000003…

  14. The "physician-led chart audit": engaging providers in fortifying a culture of safety. | PSNet

    psnet.ahrq.gov/issue/physician-led-chart-audit-engaging-providers-fortifying-culture-safety
    November 20, 2013 - Study The "physician-led chart audit": engaging providers in fortifying a culture of safety. Citation Text: Gitkind MJ, Perla RJ, Manno M, et al. The "physician-led chart audit: " engaging providers in fortifying a culture of safety. J Patient Saf. 2014;10(1):72-9. doi:10.1097/PTS.0000…

  15. Safe chemotherapy administration: using failure mode and effects analysis in computerized prescriber order entry. | PSNet

    psnet.ahrq.gov/issue/safe-chemotherapy-administration-using-failure-mode-and-effects-analysis-computerized
    October 19, 2022 - Commentary Safe chemotherapy administration: using failure mode and effects analysis in computerized prescriber order entry. Citation Text: Kozakiewicz JM, Benis LJ, Fisher SM, et al. Safe chemotherapy administration: Using failure mode and effects analysis in computerized prescriber o…

  16. Design for patient safety: a systems-based risk identification framework. | PSNet

    psnet.ahrq.gov/issue/design-patient-safety-systems-based-risk-identification-framework
    February 03, 2021 - Study Emerging Classic Design for patient safety: a systems-based risk identification framework. Citation Text: Simsekler MCE, Ward JR, Clarkson J. Design for patient safety: a systems-based risk identification framework. Ergonomics. 2018;61(8):1046-1064. doi:10…

  17. Nurse working conditions and patient safety outcomes. | PSNet

    psnet.ahrq.gov/issue/nurse-working-conditions-and-patient-safety-outcomes
    May 22, 2024 - Study Classic Nurse working conditions and patient safety outcomes. Citation Text: Stone PW, Mooney-Kane C, Larson EL, et al. Nurse Working Conditions and Patient Safety Outcomes. Med Care. 2007;45(6):571-578. doi:10.1097/mlr.0b013e3180383667. Copy Citation …

  18. Reducing readmission at an academic medical center: results of a pharmacy-facilitated discharge counseling and medication reconciliation program. | PSNet

    psnet.ahrq.gov/issue/reducing-readmission-academic-medical-center-results-pharmacy-facilitated-discharge
    August 04, 2021 - Study Reducing readmission at an academic medical center: results of a pharmacy-facilitated discharge counseling and medication reconciliation program. Citation Text: Zemaitis CT, Morris G, Cabie M, et al. Reducing Readmission at an Academic Medical Center: Results of a Pharmacy-Facilita…

  19. Anatomy of a patient safety event: a pediatric patient safety taxonomy. | PSNet

    psnet.ahrq.gov/issue/anatomy-patient-safety-event-pediatric-patient-safety-taxonomy
    May 18, 2022 - Study Anatomy of a patient safety event: a pediatric patient safety taxonomy. Citation Text: Woods DM, Johnson JK, Holl JL, et al. Anatomy of a patient safety event: a pediatric patient safety taxonomy. Qual Saf Health Care. 2005;14(6):422-7. Copy Citation Format: Google …

  20. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. | PSNet

    psnet.ahrq.gov/issue/disruptions-surgical-flow-and-their-relationship-surgical-errors-exploratory-investigation
    August 26, 2011 - Study Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Citation Text: Wiegmann DA, Elbardissi AW, Dearani JA, et al. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;…
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