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psnet.ahrq.gov/node/33560/psn-pdf
June 15, 2024 - Disclosure of Errors
June 15, 2024
Disclosure of Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/disclosure-errors
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed…
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psnet.ahrq.gov/node/33737/psn-pdf
September 01, 2012 - Preparing for Health Reform: The Federal Government
and the Nursing Workforce
September 1, 2012
Buerhaus P. Preparing for Health Reform: The Federal Government and the Nursing Workforce. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
Per…
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psnet.ahrq.gov/node/867443/psn-pdf
January 08, 2025 - Investigating the impact of a pharmacist intervention on
inappropriate prescribing practices at hospital admission
and discharge in older patients: a secondary outcome
analysis from a randomized controlled trial.
January 8, 2025
Garcia BH, Omma KK, Småbrekke L, et al. Investigating the impact of a pharmacist inter…
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psnet.ahrq.gov/node/73064/psn-pdf
March 24, 2021 - Outpatient insulin-related adverse events due to mix-up
errors: findings from two national surveillance systems,
United States, 2012-2017.
March 24, 2021
Geller AI, Conrad AO, Weidle NJ, et al. Outpatient insulin?related adverse events due to mix?up errors:
Findings from two national surveillance systems, United S…
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psnet.ahrq.gov/node/43679/psn-pdf
May 22, 2015 - Patient safety goals for the proposed Federal Health
Information Technology Safety Center.
May 22, 2015
Sittig DF, Classen D, Singh H. Patient safety goals for the proposed Federal Health Information
Technology Safety Center. J Am Med Inform Assoc. 2015;22(2):472-8. doi:10.1136/amiajnl-2014-002988.
https://psnet.a…
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psnet.ahrq.gov/node/44178/psn-pdf
July 03, 2016 - A trigger tool to detect harm in pediatric inpatient
settings.
July 3, 2016
Stockwell DC, Bisarya H, Classen D, et al. A trigger tool to detect harm in pediatric inpatient settings.
Pediatrics. 2015;135(6):1036-42. doi:10.1542/peds.2014-2152.
https://psnet.ahrq.gov/issue/trigger-tool-detect-harm-pediatric-inpatien…
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psnet.ahrq.gov/node/853234/psn-pdf
September 06, 2023 - Perceptions and attitudes of pediatricians and families
with regard to pediatric medication errors at home.
September 6, 2023
de Dios JG, Lopez-Pineda A, Juan GM-P, et al. Perceptions and attitudes of pediatricians and families with
regard to pediatric medication errors at home. BMC Pediatr. 2023;23(1):380. doi:10.…
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psnet.ahrq.gov/node/35611/psn-pdf
June 23, 2010 - Error or "act of God"? A study of patients' and operating
room team members' perceptions of error definition,
reporting, and disclosure.
June 23, 2010
Espin S, Levinson W, Regehr G, et al. Error or "act of God"? A study of patients' and operating room team
members' perceptions of error definition, reporting, and d…
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psnet.ahrq.gov/node/41497/psn-pdf
April 05, 2013 - Avoiding handover fumbles: a controlled trial of a
structured handover tool versus traditional handover
methods.
April 5, 2013
Payne CE, Stein JM, Leong T, et al. Avoiding handover fumbles: a controlled trial of a structured handover
tool versus traditional handover methods. BMJ Qual Saf. 2012;21(11):925-32. doi:1…
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psnet.ahrq.gov/node/36163/psn-pdf
September 29, 2010 - Improving the bar-coded medication administration
system at the Department of Veterans Affairs.
September 29, 2010
Mills PD, Neily J, Mims E, et al. Improving the bar-coded medication administration system at the
Department of Veterans Affairs. Am J Health Syst Pharm. 2006;63(15):1442-7.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/41611/psn-pdf
November 23, 2012 - Self-reported uptake of recommendations after
dissemination of medication incident alerts.
November 23, 2012
Cheung K-C, Wensing M, Bouvy ML, et al. Self-reported uptake of recommendations after dissemination of
medication incident alerts. BMJ Qual Saf. 2012;21(12):1009-18. doi:10.1136/bmjqs-2012-000828.
https://p…
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psnet.ahrq.gov/node/46450/psn-pdf
August 20, 2018 - Improving Diagnostic Quality and Safety Final Report.
August 20, 2018
Washington, DC: National Quality Forum. September 19, 2017.
https://psnet.ahrq.gov/issue/improving-diagnostic-quality-and-safety-final-report
Although diagnostic error is a well-recognized source of preventable patient harm, measuring and
mitiga…
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psnet.ahrq.gov/node/48057/psn-pdf
June 26, 2019 - Multicenter study to evaluate the benefits of technology-
assisted workflow on i.v. room efficiency, costs, and
safety.
June 26, 2019
Eckel SF, Higgins JP, Hess E, et al. Multicenter study to evaluate the benefits of technology-assisted
workflow on i.v. room efficiency, costs, and safety. Am J Health-Syst Pharm. 2…
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psnet.ahrq.gov/node/39444/psn-pdf
June 28, 2010 - The relationship between organizational leadership for
safety and learning from patient safety events.
June 28, 2010
Ginsburg LR, Chuang Y-T, Berta WB, et al. The relationship between organizational leadership for safety
and learning from patient safety events. Health Serv Res. 2010;45(3):607-632. doi:10.1111/j.147…
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psnet.ahrq.gov/node/42721/psn-pdf
December 12, 2014 - Infusional chemotherapy and medication errors in a
tertiary care pediatric cancer unit in a resource-limited
setting.
December 12, 2014
Dhamija M, Kapoor G, Juneja A. Infusional chemotherapy and medication errors in a tertiary care pediatric
cancer unit in a resource-limited setting. J Pediatr Hematol Oncol. 2014;…
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psnet.ahrq.gov/node/837136/psn-pdf
May 18, 2022 - What can we learn from in-depth analysis of human errors
resulting in diagnostic errors in the emergency
department: an analysis of serious adverse event reports.
May 18, 2022
Baartmans MC, Hooftman J, Zwaan L, et al. What can we learn from in-depth analysis of human errors
resulting in diagnostic errors in the em…
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psnet.ahrq.gov/node/44042/psn-pdf
November 03, 2015 - Deployment of rapid response teams by 31 hospitals in a
statewide collaborative.
November 3, 2015
Stolldorf DP, Jones CB. Deployment of rapid response teams by 31 hospitals in a statewide collaborative.
Jt Comm J Qual Patient Saf. 2015;41(4):186-191.
https://psnet.ahrq.gov/issue/deployment-rapid-response-teams-31-…
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psnet.ahrq.gov/node/39729/psn-pdf
September 20, 2011 - Contextual errors and failures in individualizing patient
care: a multicenter study.
September 20, 2011
Weiner SJ, Schwartz A, Weaver FM, et al. Contextual errors and failures in individualizing patient care: a
multicenter study. Ann Intern Med. 2010;153(2):69-75. doi:10.7326/0003-4819-153-2-201007200-00002.
https…
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psnet.ahrq.gov/node/37546/psn-pdf
June 14, 2011 - Effective interventions and implementation strategies to
reduce adverse drug events in the Veterans Affairs (VA)
system.
June 14, 2011
Mills PD, Neily J, Kinney LM, et al. Effective interventions and implementation strategies to reduce adverse
drug events in the Veterans Affairs (VA) system. Qual Saf Health Care. …
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psnet.ahrq.gov/node/45894/psn-pdf
June 23, 2017 - Tell me how pleased you are with your workplace, and I
will tell you how often you wash your hands.
June 23, 2017
Sholomovich L, Magnezi R. Tell me how pleased you are with your workplace, and I will tell you how often
you wash your hands. Am J Infect Control. 2017;45(6):677-681. doi:10.1016/j.ajic.2016.12.005.
ht…