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  1. ASHP guidelines on remote medication order processing. | PSNet

    psnet.ahrq.gov/issue/ashp-guidelines-remote-medication-order-processing
    April 19, 2013 - Commentary ASHP guidelines on remote medication order processing. Citation Text: Processing ASHPEP on RMO, Thompson B, Conrad G, et al. ASHP guidelines on remote medication order processing. Am J Health Syst Pharm. 2010;67(8):672-7. doi:10.2146/sp100003. Copy Citation Format: …

  2. Implementing smart infusion pumps with dose-error reduction software: real-world experiences. | PSNet

    psnet.ahrq.gov/issue/implementing-smart-infusion-pumps-dose-error-reduction-software-real-world-experiences
    May 26, 2021 - Commentary Implementing smart infusion pumps with dose-error reduction software: real-world experiences. Citation Text: Heron C. Implementing smart infusion pumps with dose-error reduction software: real-world experiences. Br J Nurs. 2017;26(8):S13-S16. doi:10.12968/bjon.2017.26.8.S13. …

  3. Scandal as a sentinel event—recognizing hidden cost–quality trade-offs. | PSNet

    psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-trade-offs
    November 04, 2020 - Commentary Scandal as a sentinel event—recognizing hidden cost–quality trade-offs. Citation Text: Bloche G. Scandal as a Sentinel Event--Recognizing Hidden Cost-Quality Trade-offs. N Engl J Med. 2016;374(11):1001-3. doi:10.1056/NEJMp1502629. Copy Citation Format: DOI Google…

  4. Patient safety climate in 92 US hospitals: differences by work area and discipline. | PSNet

    psnet.ahrq.gov/issue/patient-safety-climate-92-us-hospitals-differences-work-area-and-discipline
    September 02, 2009 - Study Patient safety climate in 92 US hospitals: differences by work area and discipline. Citation Text: Singer SJ, Gaba DM, Falwell A, et al. Patient safety climate in 92 US hospitals: differences by work area and discipline. Med Care. 2009;47(1):23-31. doi:10.1097/MLR.0b013e31817e189…

  5. Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting. | PSNet

    psnet.ahrq.gov/issue/adverse-events-anaesthetic-practice-qualitative-study-definition-discussion-and-reporting
    April 18, 2011 - Study Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting. Citation Text: Smith AF, Goodwin D, Mort M, et al. Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting. Br J Anaesth. 2006;96(6):715-21…

  6. Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. | PSNet

    psnet.ahrq.gov/issue/effect-comprehensive-obstetric-patient-safety-program-compensation-payments-and-sentinel
    July 26, 2010 - Study Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. Citation Text: Grunebaum A, Chervenak F, Skupski D. Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. Am J Obstet Gyneco…

  7. Delivering high reliability in maternity care: in situ simulation as a source of organisational resilience. | PSNet

    psnet.ahrq.gov/issue/delivering-high-reliability-maternity-care-situ-simulation-source-organisational-resilience
    April 05, 2023 - Commentary Emerging Classic Delivering high reliability in maternity care: in situ simulation as a source of organisational resilience. Citation Text: Macrae C, Draycott T. Delivering high reliability in maternity care: In situ simulation as a source of organisa…

  8. Keeping Patients Safe: Transforming the Work Environment of Nurses. | PSNet

    psnet.ahrq.gov/issue/keeping-patients-safe-transforming-work-environment-nurses
    July 05, 2016 - Book/Report Classic Keeping Patients Safe: Transforming the Work Environment of Nurses. Citation Text: Keeping Patients Safe: Transforming the Work Environment of Nurses. Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Healt…

  9. Elimination of emergency department medication errors due to estimated weights. | PSNet

    psnet.ahrq.gov/issue/elimination-emergency-department-medication-errors-due-estimated-weights
    July 08, 2020 - Commentary Elimination of emergency department medication errors due to estimated weights. Citation Text: Greenwalt M, Griffen D, Wilkerson J. Elimination of Emergency Department Medication Errors Due To Estimated Weights. BMJ Qual Improv Rep. 2017;6(1). doi:10.1136/bmjquality.u214416.w5…

  10. The ongoing quality improvement journey: next stop, high reliability. | PSNet

    psnet.ahrq.gov/issue/ongoing-quality-improvement-journey-next-stop-high-reliability
    January 23, 2012 - Commentary The ongoing quality improvement journey: next stop, high reliability. Citation Text: Chassin MR, Loeb JM. The ongoing quality improvement journey: next stop, high reliability. Health Aff (Millwood). 2011;30(4):559-68. doi:10.1377/hlthaff.2011.0076. Copy Citation Format…

  11. Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness. | PSNet

    psnet.ahrq.gov/issue/medical-harm-historical-conceptual-and-ethical-dimensions-iatrogenic-illness
    May 13, 2020 - Book/Report Classic Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness. Citation Text: Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness. Sharpe VA, Faden AI. Cambridge NY; Cambridge University…

  12. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. | PSNet

    psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm
    June 21, 2016 - Book/Report RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Citation Text: RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015. Copy Citation Save Save to your library Print …

  13. Support methods for healthcare professionals who are second victims: an integrative review. | PSNet

    psnet.ahrq.gov/issue/support-methods-healthcare-professionals-who-are-second-victims-integrative-review
    April 27, 2022 - Review Support methods for healthcare professionals who are second victims: an integrative review. Citation Text: Support methods for healthcare professionals who are second victims: an integrative review. Neft MW, Sekula K, Zoucha R, et al. AANA J. 2022;90(3):189-196.  Copy Cit…

  14. The real malady of Marcel Proust and what it reveals about diagnostic errors in medicine. | PSNet

    psnet.ahrq.gov/issue/real-malady-marcel-proust-and-what-it-reveals-about-diagnostic-errors-medicine
    September 27, 2022 - Commentary The real malady of Marcel Proust and what it reveals about diagnostic errors in medicine. Citation Text: Douglas Y. The real malady of Marcel Proust and what it reveals about diagnostic errors in medicine. Med Hypotheses. 2016;90:14-8. doi:10.1016/j.mehy.2016.02.024. Copy Ci…

  15. Social risk, health inequity, and patient safety. | PSNet

    psnet.ahrq.gov/issue/social-risk-health-inequity-and-patient-safety
    September 28, 2022 - Commentary Social risk, health inequity, and patient safety. Citation Text: Boisvert S. Social risk, health inequity, and patient safety. J Healthc Risk Manag. 2022;42(2):18-25. doi:10.1002/jhrm.21519. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7…

  16. The 100,000 Lives Campaign: setting a goal and a deadline for improving health care quality. | PSNet

    psnet.ahrq.gov/issue/100000-lives-campaign-setting-goal-and-deadline-improving-health-care-quality
    February 29, 2012 - Commentary The 100,000 Lives Campaign: setting a goal and a deadline for improving health care quality. Citation Text: Berwick DM, Calkins DR, McCannon CJ, et al. The 100 000 Lives Campaign. JAMA. 2006;295(3). doi:10.1001/jama.295.3.324. Copy Citation Format: DOI Google S…

  17. The problem with 'never events'. | PSNet

    psnet.ahrq.gov/issue/problem-never-events
    July 12, 2023 - Commentary The problem with 'never events'. Citation Text: Zaslow J, Fortier J, Garber G. The problem with ‘never events’. BMJ Qual Saf. 2024;33(9):613-616. doi:10.1136/bmjqs-2023-016981. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

  18. Influence of house-staff experience on teaching-hospital mortality: the "July Phenomenon" revisited. | PSNet

    psnet.ahrq.gov/issue/influence-house-staff-experience-teaching-hospital-mortality-july-phenomenon-revisited
    March 04, 2015 - Study Influence of house-staff experience on teaching-hospital mortality: the "July Phenomenon" revisited. Citation Text: van Walraven C, Jennings A, Wong J, et al. Influence of house-staff experience on teaching-hospital mortality: the "July phenomenon" revisited. J Hosp Med. 2011;6(7…

  19. Risks related to patient bed safety. | PSNet

    psnet.ahrq.gov/issue/risks-related-patient-bed-safety
    July 19, 2023 - Commentary Risks related to patient bed safety. Citation Text: Sharkey JE, Van Leuven K, Radovich P. Risks related to patient bed safety. J Nurs Care Qual. 2012;27(4):346-51. doi:10.1097/NCQ.0b013e318264744b. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X…

  20. From blaming to learning: re-framing organisational learning from adverse incidents. | PSNet

    psnet.ahrq.gov/issue/blaming-learning-re-framing-organisational-learning-adverse-incidents
    October 05, 2022 - Study From blaming to learning: re-framing organisational learning from adverse incidents. Citation Text: Gray D, Williams S. From blaming to learning: re‐framing organisational learning from adverse incidents. Learn Org. 2011;18(6):438-453. doi:10.1108/09696471111171295. Copy Citatio…
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