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psnet.ahrq.gov/issue/high-risk-high-alert-medication-management-practices-regional-state-psychiatric-facility
January 06, 2017 - Study
High-risk, high-alert medication management practices in a regional state psychiatric facility.
Citation Text:
McKee J, Cleary S. High-Risk, High-Alert Medication Management Practices in a Regional State Psychiatric Facility. Hosp Pharm. 2007;42(4):323-330. doi:10.1310/hpj4204-323.…
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psnet.ahrq.gov/issue/strengthening-medical-error-meme-pool
August 08, 2012 - Commentary
Strengthening the medical error "meme pool."
Citation Text:
Mazer BL, Nabhan C. Strengthening the Medical Error "Meme Pool". J Gen Intern Med. 2019;34(10):2264-2267. doi:10.1007/s11606-019-05156-7.
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psnet.ahrq.gov/issue/prevent-medication-errors-new-years-resolution-teaching-patients-about-their-medications
January 18, 2011 - Commentary
Prevent medication errors: a New Year's resolution: teaching patients about their medications.
Citation Text:
Polzien G. Prevent medication errors: A New Year's resolution: teaching patients about their medications. Home Healthc Nurse. 2007;25(1):59-62.
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psnet.ahrq.gov/issue/challenges-defining-and-measuring-diagnostic-error
February 24, 2021 - Commentary
The challenges in defining and measuring diagnostic error.
Citation Text:
Zwaan L, Singh H. The challenges in defining and measuring diagnostic error. Diagnosis (Berl). 2015;2(2):97-103. doi:10.1515/dx-2014-0069.
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psnet.ahrq.gov/issue/performing-wrong-procedure
April 24, 2018 - Commentary
Performing the wrong procedure.
Citation Text:
Minnier T, Phrampus P, Waddell L. Performing the Wrong Procedure. JAMA. 2016;316(11):1207-1208. doi:10.1001/jama.2016.9134.
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psnet.ahrq.gov/issue/surgical-never-events-how-common-are-adverse-occurrences
November 16, 2022 - Commentary
Surgical 'never events': how common are adverse occurrences?
Citation Text:
West JC. Surgical ‘never events’: How common are adverse occurrences? Journal of Healthcare Risk Management. 2009;26(1). doi:10.1002/jhrm.5600260105.
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psnet.ahrq.gov/issue/probability-error-diagnosis-conjunction-fallacy-among-beginning-medical-students
June 21, 2017 - Study
Probability error in diagnosis: the conjunction fallacy among beginning medical students.
Citation Text:
Rao G. Probability error in diagnosis: the conjunction fallacy among beginning medical students. Fam Med. 2009;41(4):262-5.
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psnet.ahrq.gov/issue/otolaryngologists-responses-errors-and-adverse-events
October 27, 2010 - Study
Otolaryngologists' responses to errors and adverse events.
Citation Text:
Lander LI, Connor JA, Shah RK, et al. Otolaryngologists' responses to errors and adverse events. Laryngoscope. 2006;116(7):1114-20.
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psnet.ahrq.gov/issue/how-reliable-your-hospital-qualitative-framework-analysing-reliability-levels
October 19, 2022 - Commentary
How reliable is your hospital? A qualitative framework for analysing reliability levels.
Citation Text:
Ikkersheim DE, Berg M. How reliable is your hospital? A qualitative framework for analysing reliability levels. BMJ Qual Saf. 2011;20(9):785-790.
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psnet.ahrq.gov/issue/reduction-pediatric-identification-band-errors-quality-collaborative
March 14, 2022 - Study
Reduction in pediatric identification band errors: a quality collaborative.
Citation Text:
Phillips SC, Saysana M, Worley S, et al. Reduction in pediatric identification band errors: a quality collaborative. Pediatrics. 2012;129(6):e1587-93. doi:10.1542/peds.2011-1911.
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psnet.ahrq.gov/issue/aspen-parenteral-nutrition-safety-consensus-recommendations-translation-practice
February 17, 2015 - Commentary
ASPEN parenteral nutrition safety consensus recommendations: translation into practice.
Citation Text:
Ayers P, Adams S, Boullata JI, et al. A.S.P.E.N. parenteral nutrition safety consensus recommendations: translation into practice. Nutr Clin Pract. 2014;29(3):277-82. doi:10.…
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psnet.ahrq.gov/issue/intravenous-admixture-preparation-considerations-parts-9-and-9-b-error-prevention-intravenous
December 22, 2021 - Special or Theme Issue
Intravenous admixture preparation considerations, Parts 9-A and 9-B: error prevention in intravenous admixture preparation.
Citation Text:
Intravenous admixture preparation considerations, Parts 9-A and 9-B: error prevention in intravenous admixture preparation. Al…
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psnet.ahrq.gov/issue/confronting-colleague-who-covers-medical-error
September 16, 2020 - Commentary
Confronting a colleague who covers up a medical error.
Citation Text:
Brody H. Confronting a colleague who covers up a medical error. Am Fam Physician. 2006;73(7):1272, 1274.
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psnet.ahrq.gov/issue/nurse-led-approach-developing-and-implementing-collaborative-count-policy
January 18, 2012 - Commentary
A nurse-led approach to developing and implementing a collaborative count policy.
Citation Text:
Norton EK, Micheli AJ, Gedney J, et al. A nurse-led approach to developing and implementing a collaborative count policy. AORN J. 2012;95(2):222-7. doi:10.1016/j.aorn.2011.11.009. …
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psnet.ahrq.gov/issue/preventing-complications-central-venous-catheterization
September 02, 2015 - Review
Preventing complications of central venous catheterization.
Citation Text:
McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348(12):1123-33.
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psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems-months-shutdown-then
July 18, 2018 - Newspaper/Magazine Article
Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go.
Citation Text:
Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go. Massey W, Keith …
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psnet.ahrq.gov/issue/safety-hospital-stroke-care
December 02, 2020 - Study
The safety of hospital stroke care.
Citation Text:
Holloway RG, Tuttle D, Baird T, et al. The safety of hospital stroke care. Neurology. 2007;68(8):550-555.
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psnet.ahrq.gov/issue/tapping-front-line-knowledge-identifying-problems-they-occur-helps-enhance-patient-safety
July 21, 2009 - Newspaper/Magazine Article
Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety.
Citation Text:
Luther K, Resar RK. Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety. Healthcare executive. 2013;28(1):84-…
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psnet.ahrq.gov/issue/what-causes-near-misses-and-how-are-they-mitigated
April 16, 2008 - Study
What causes near-misses and how are they mitigated?
Citation Text:
Speroni KG, Fisher J, Dennis M, et al. What causes near-misses and how are they mitigated? Nursing (Brux). 2013;43(4):19-24. doi:10.1097/01.NURSE.0000427995.92553.ef.
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psnet.ahrq.gov/issue/meaning-justice-safety-incident-reporting
April 11, 2011 - Commentary
The meaning of justice in safety incident reporting.
Citation Text:
Weiner BJ, Hobgood C, Lewis MA. The meaning of justice in safety incident reporting. Soc Sci Med. 2008;66(2):403-13.
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