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Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event. | PSNet

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June 19, 2019 - Newspaper/Magazine Article Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event. Citation Text: Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event. ISMP Medication Safety Alert! Acute Ca…

The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. | PSNet

psnet.ahrq.gov/issue/challenger-launch-decision-risky-technology-culture-and-deviance-nasa

November 18, 2015 - Book/Report Classic The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. Citation Text: The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. Vaughan D. Chicago, IL: University of Chicago Press; 1996. ISBN…

AHRQ Communication and Optimal Resolution (CANDOR) Toolkit. | PSNet

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May 25, 2016 - Toolkit AHRQ Communication and Optimal Resolution (CANDOR) Toolkit. Citation Text: AHRQ Communication and Optimal Resolution (CANDOR) Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. Copy Citation Save Save to your library Print …

Kaiser Permanente's performance improvement system, part 4: creating a learning organization. | PSNet

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July 19, 2023 - Commentary Kaiser Permanente's performance improvement system, part 4: creating a learning organization. Citation Text: Schilling L, Dearing JW, Staley P, et al. Kaiser Permanente's performance improvement system, Part 4: Creating a learning organization. Jt Comm J Qual Patient Saf. 2011…

Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors. | PSNet

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August 16, 2023 - Book/Report Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors. Citation Text: Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors. Schlesinger M, Grob R, Gleason K, et al. Rock…

Intravenous infusion safety technology: return on investment. | PSNet

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October 29, 2017 - Study Intravenous infusion safety technology: return on investment. Citation Text: Danello SH, Maddox RR, Schaack GJ. Intravenous Infusion Safety Technology: Return on Investment. Hosp Pharm. 2010;44(8):680-688. doi:10.1310/hpj4408-680. Copy Citation Format: DOI Google Scho…

Guide to Patient and Family Engagement in Hospital Quality and Safety. | PSNet

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December 24, 2008 - Multi-use Website Guide to Patient and Family Engagement in Hospital Quality and Safety. Citation Text: Guide to Patient and Family Engagement in Hospital Quality and Safety. Rockville, MD: Agency for Healthcare Research and Quality; June 2013. Copy Citation Save …

A systems approach to address the impact of second victim phenomenon. | PSNet

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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. Copy Citation Format:…

Through the Patient’s Eyes: Understanding and Promoting Patient-Centered Care. | PSNet

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October 04, 2006 - Book/Report Classic Through the Patient’s Eyes: Understanding and Promoting Patient-Centered Care. Citation Text: Through the Patient’s Eyes: Understanding and Promoting Patient-Centered Care. Gerteis M, Edgman-Levitan S, Daley J, et al. San Francisco: Jossey-Ba…

New technology, new errors: how to prime an upgrade of an insulin infusion pump. | PSNet

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July 14, 2010 - Commentary New technology, new errors: how to prime an upgrade of an insulin infusion pump. Citation Text: Rule AM, Drincic A, Galt K. New technology, new errors: how to prime an upgrade of an insulin infusion pump. Jt Comm J Qual Patient Saf. 2007;33(3):155-62. Copy Citation Forma…

Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance. | PSNet

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June 21, 2015 - Study Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance. Citation Text: Bhakta RT, Stockwell DC. Transitions of care in the pediatric cardiac intensive care unit*. Crit Care Med…

Medication reconciliation: a qualitative analysis of clinicians' perceptions. | PSNet

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October 10, 2015 - Study Medication reconciliation: a qualitative analysis of clinicians' perceptions. Citation Text: Vogelsmeier A, Pepper GA, Oderda L, et al. Medication reconciliation: A qualitative analysis of clinicians' perceptions. Res Social Adm Pharm. 2013;9(4):419-30. doi:10.1016/j.sapharm.201…

Promoting patient safety with perioperative hand-off communication. | PSNet

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April 22, 2011 - Commentary Promoting patient safety with perioperative hand-off communication. Citation Text: Robinson NL. Promoting Patient Safety With Perioperative Hand-off Communication. J Perianesth Nurs. 2016;31(3):245-53. doi:10.1016/j.jopan.2014.08.144. Copy Citation Format: DOI Go…

Pharmacist staffing, technology use, and implementation of medication safety practices in rural hospitals. | PSNet

psnet.ahrq.gov/issue/pharmacist-staffing-technology-use-and-implementation-medication-safety-practices-rural

September 27, 2010 - Study Pharmacist staffing, technology use, and implementation of medication safety practices in rural hospitals. Citation Text: Casey M, Moscovice I, Davidson G. Pharmacist staffing, technology use, and implementation of medication safety practices in rural hospitals. J Rural Health. 2…

National Reporting and Learning System Research and Development. | PSNet

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April 06, 2016 - Book/Report National Reporting and Learning System Research and Development. Citation Text: National Reporting and Learning System Research and Development. Mayer E, Flott K, Callahan R, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research Centre; 2016. Copy Citatio…

Under-mined. | PSNet

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October 27, 2010 - Newspaper/Magazine Article Under-mined. Citation Text: Greene J. Under-mined. Hospitals & health networks. 2006;80(12):38-40, 42, 44, 1. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation …

With Safety in Mind: Mental Health Services and Patient Safety. | PSNet

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August 07, 2018 - Book/Report With Safety in Mind: Mental Health Services and Patient Safety. Citation Text: With Safety in Mind: Mental Health Services and Patient Safety. Scobie S, Minghella E, Dale C, et al. London, UK: National Patient Safety Agency; 2006. Copy Citation Save …

Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals. | PSNet

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October 16, 2012 - Government Resource Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals. Citation Text: Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals. Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January…

Patient safety and medical malpractice: a case study. | PSNet

psnet.ahrq.gov/issue/patient-safety-and-medical-malpractice-case-study

May 20, 2015 - Commentary Patient safety and medical malpractice: a case study. Citation Text: Brennan TA, Mello MM. Patient safety and medical malpractice: a case study. Ann Intern Med. 2003;139(4):267-73. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML …

Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems. | PSNet

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January 20, 2010 - Book/Report Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems. Citation Text: Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems. Wright S. Washington, DC: US Department of Health and Human Services, Office of t…

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