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Addressing delays in medication administration for patients transferred from the hospital to the nursing home: a pilot quality improvement project. | PSNet

psnet.ahrq.gov/issue/addressing-delays-medication-administration-patients-transferred-hospital-nursing-home-pilot

November 16, 2022 - Study Addressing delays in medication administration for patients transferred from the hospital to the nursing home: a pilot quality improvement project. Citation Text: Ward KT, Bates-Jensen B, Eslami MS, et al. Addressing delays in medication administration for patients transferred …

Escape Fire: Lessons for the Future of Health Care. | PSNet

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July 05, 2008 - Book/Report Classic Escape Fire: Lessons for the Future of Health Care. Citation Text: Escape Fire: Lessons for the Future of Health Care. Berwick DM. Washington DC: Commonwealth Fund; 2002. Copy Citation Save Save to your library P…

Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites. | PSNet

psnet.ahrq.gov/issue/diagnostic-errors-interpretation-pediatric-musculoskeletal-radiographs-common-injury-sites

August 02, 2015 - Study Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites. Citation Text: Bisset GS, Crowe J. Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites. Pediatr Radiol. 2014;44(5):552-7. doi:10.1007…

Patient safety culture: factors that influence clinician involvement in patient safety behaviours. | PSNet

psnet.ahrq.gov/issue/patient-safety-culture-factors-influence-clinician-involvement-patient-safety-behaviours

April 16, 2014 - Study Patient safety culture: factors that influence clinician involvement in patient safety behaviours. Citation Text: Wakefield JG, McLaws M-L, Whitby M, et al. Patient safety culture: factors that influence clinician involvement in patient safety behaviours. Qual Saf Health Care. 20…

Pediatric medication administration errors and workflow following implementation of a bar code medication administration system. | PSNet

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July 02, 2019 - Study Pediatric medication administration errors and workflow following implementation of a bar code medication administration system. Citation Text: Hardmeier A, Tsourounis C, Moore M, et al. Pediatric medication administration errors and workflow following implementation of a bar code …

Positive deviance: a new tool for infection prevention and patient safety. | PSNet

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March 09, 2022 - Commentary Positive deviance: a new tool for infection prevention and patient safety. Citation Text: Marra AR, Santos OFPD, Neto MC, et al. Positive Deviance: A New Tool for Infection Prevention and Patient Safety. Curr Infect Dis Rep. 2013. Copy Citation Format: Google Sch…

During the pandemic, aspire to identify and prevent medication errors and to avoid blaming attitudes. | PSNet

psnet.ahrq.gov/issue/during-pandemic-aspire-identify-and-prevent-medication-errors-and-avoid-blaming-attitudes

September 07, 2022 - Newspaper/Magazine Article During the pandemic, aspire to identify and prevent medication errors and to avoid blaming attitudes. Citation Text: During the pandemic, aspire to identify and prevent medication errors and to avoid blaming attitudes. ISMP Medication Safety Alert! Acute care e…

Workforce safety key to patient safety. | PSNet

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December 09, 2020 - Newspaper/Magazine Article Workforce safety key to patient safety. Citation Text: Workforce safety key to patient safety. McGaffigan P, Gerwig K, Kingston MB. Healthcare Executive. 2020 Nov;35(6):48-50. Copy Citation Save Save to your library Print …

ReCASTing the RCA: an improved model for performing root cause analyses. | PSNet

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November 10, 2010 - Commentary ReCASTing the RCA: an improved model for performing root cause analyses. Citation Text: Pham JC, Kim GR, Natterman JP, et al. ReCASTing the RCA: An Improved Model for Performing Root Cause Analyses. American Journal of Medical Quality. 2010;25(3). doi:10.1177/1062860609359533…

Risk mitigation in large scale systems: lessons from high reliability organizations. | PSNet

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January 30, 2019 - Commentary Classic Risk mitigation in large scale systems: lessons from high reliability organizations. Citation Text: Risk mitigation in large scale systems: lessons from high reliability organizations. Grabowski M, Roberts K. Calif Manag Rev. 1997;39(4):152-16…

Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study. | PSNet

psnet.ahrq.gov/issue/patient-safety-intensive-care-results-multinational-sentinel-events-evaluation-see-study

March 03, 2011 - Study Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study. Citation Text: Valentin A, Capuzzo M, Guidet B, et al. Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study. Intensive Care …

Identifying organizational cultures that promote patient safety. | PSNet

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June 16, 2011 - Study Identifying organizational cultures that promote patient safety. Citation Text: Singer SJ, Falwell A, Gaba DM, et al. Identifying organizational cultures that promote patient safety. Health Care Manag Rev. 2009;34(4):300-311. doi:10.1097/HMR.0b013e3181afc10c. Copy Citation …

Simulation to Improve Patient Safety: Getting Started. | PSNet

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June 26, 2024 - Book/Report Simulation to Improve Patient Safety: Getting Started. Citation Text: Deutsch ES, Bajaj K. Simulation To Improve Patient Safety: Getting Started. Rockville, MD: Agency for Healthcare Research and Quality; July 2024. Publication No. 24-0055. Copy Citation Format: …

Safety-I, Safety-II and burnout: how complexity science can help clinician wellness. | PSNet

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December 20, 2017 - Review Safety-I, Safety-II and burnout: how complexity science can help clinician wellness. Citation Text: Smaggus A. Safety-I, Safety-II and burnout: how complexity science can help clinician wellness. BMJ Qual Saf. 2019;28(8):667-671. doi:10.1136/bmjqs-2018-009147. Copy Citation …

Patient safety curriculum for surgical residency programs: results of a national consensus conference. | PSNet

psnet.ahrq.gov/issue/patient-safety-curriculum-surgical-residency-programs-results-national-consensus-conference

September 16, 2009 - Commentary Patient safety curriculum for surgical residency programs: results of a national consensus conference. Citation Text: Sachdeva AK, Philibert I, Leach DC, et al. Patient safety curriculum for surgical residency programs: results of a national consensus conference. Surgery. 20…

Discharge rounds in the 80-hour workweek: importance of the trauma nurse practitioner. | PSNet

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October 19, 2022 - Study Discharge rounds in the 80-hour workweek: importance of the trauma nurse practitioner. Citation Text: Haan JM, Dutton RP, Willis M, et al. Discharge rounds in the 80-hour workweek: importance of the trauma nurse practitioner. J Trauma. 2007;63(2):339-43. Copy Citation Forma…

The eNOTSS platform for surgeons’ nontechnical skills performance improvement. | PSNet

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July 01, 2017 - Commentary The eNOTSS platform for surgeons’ nontechnical skills performance improvement. Citation Text: Pradarelli JC, Yule S, Smink DS. The eNOTSS Platform for Surgeons’ Nontechnical Skills Performance Improvement. JAMA Surg. 2020;155(5):438-439. doi:10.1001/jamasurg.2019.5880. Copy …

Fear of Covid-19 leads other patients to decline critical treatment. | PSNet

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June 24, 2020 - Newspaper/Magazine Article Fear of Covid-19 leads other patients to decline critical treatment. Citation Text: Hafner K. Fear of Covid-19 leads other patients to decline critical treatment. New York Times. 2020;May 25. Copy Citation Format: Google Scholar BibTeX EndNote X3 …

Medication errors involving the intravenous administration route: characteristics of voluntarily reported medication errors. | PSNet

psnet.ahrq.gov/issue/medication-errors-involving-intravenous-administration-route-characteristics-voluntarily

January 31, 2018 - Review Medication errors involving the intravenous administration route: characteristics of voluntarily reported medication errors. Citation Text: Wolf ZR. Medication Errors Involving the Intravenous Administration Route: Characteristics of Voluntarily Reported Medication Errors. J Infus…

The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives. | PSNet

psnet.ahrq.gov/issue/vha-new-england-medication-error-prevention-initiative-model-long-term-improvement

January 04, 2017 - Commentary The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives. Citation Text: Lesar TS, Anderson ER, Fields J, et al. The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives…

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