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psnet.ahrq.gov/issue/us-nursing-homes-where-covid-19-killed-scores-even-reports-maggots-and-rape-dont-dock-five
December 22, 2021 - Newspaper/Magazine Article
In U.S. nursing homes, where Covid-19 killed scores, even reports of maggots and rape don’t dock five-star ratings.
Citation Text:
In U.S. nursing homes, where Covid-19 killed scores, even reports of maggots and rape don’t dock five-star ratings. Silver-Greenbe…
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psnet.ahrq.gov/issue/medication-therapy-management-programs-forming-new-cornerstone-quality-and-safety-medicare
January 06, 2017 - Commentary
Medication therapy management programs: forming a new cornerstone for quality and safety in Medicare.
Citation Text:
Smith SR, Clancy CM. Medication therapy management programs: forming a new cornerstone for quality and safety in medicare. Am J Med Qual. 2006;21(4):276-9.
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psnet.ahrq.gov/issue/call-excellence
May 20, 2009 - Commentary
A call to excellence.
Citation Text:
Clancy CM, Scully T. A call to excellence. Health Aff (Millwood). 2003;22(2):113-5.
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psnet.ahrq.gov/issue/path-safety-benefits-2005-patient-safety-and-quality-improvement-act
June 03, 2015 - Commentary
Path to safety: benefits of the 2005 Patient Safety and Quality Improvement Act.
Citation Text:
McBride D, Greening A, Redmond D. Path to safety: benefits of the 2005 Patient Safety and Quality Improvement Act. Healthc Financ Manage. 2006;60(6):84-8.
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psnet.ahrq.gov/issue/cognitive-load-theory-and-its-impact-diagnostic-accuracy
August 07, 2024 - Book/Report
Cognitive Load Theory and its Impact on Diagnostic Accuracy.
Citation Text:
Cognitive Load Theory and its Impact on Diagnostic Accuracy. Knees M, Raffel KE, Kissler M, et al. Rockville, MD: Agency for Healthcare Research and Quality; May 2024. Publication No. 24-0010-2-EF.
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psnet.ahrq.gov/issue/adoption-technology-improve-medication-safety-perspectives-pharmacy-directors
February 15, 2011 - Study
Adoption of technology to improve medication safety: perspectives of pharmacy directors.
Citation Text:
Bussard BE, McAlearney AS, Pedersen CA, et al. Adoption of Technology to Improve Medication Safety. J Patient Saf. 2008;2(4). doi:10.1097/01.jps.0000236914.48955.99.
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psnet.ahrq.gov/issue/using-ismp-medication-safety-self-assessment-improve-medication-use-processes
January 05, 2017 - Study
Using the ISMP Medication Safety Self-Assessment to improve medication use processes.
Citation Text:
Lesar TS, Mattis A, Anderson E, et al. Using the ISMP Medication Safety Self-Assessment to improve medication use processes. Jt Comm J Qual Saf. 2003;29(5):211-26.
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psnet.ahrq.gov/issue/maximize-patient-safety-advanced-root-cause-analysis
November 18, 2011 - Book/Report
Maximize Patient Safety with Advanced Root Cause Analysis.
Citation Text:
Maximize Patient Safety with Advanced Root Cause Analysis. Corbett C, Clapper C, Johnson KM, et al. Middleton, MA: HCPro; 2004. ISBN: 1578393485
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psnet.ahrq.gov/issue/why-patient-safety-such-tough-nut-crack
May 03, 2023 - Commentary
Why patient safety is such a tough nut to crack.
Citation Text:
Leistikow IP, Kalkman CJ, de Bruijn H. Why patient safety is such a tough nut to crack. BMJ. 2011;342:d3447. doi:10.1136/bmj.d3447.
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psnet.ahrq.gov/issue/opioids-iatrogenic-harm-and-disclosure-medical-error
November 21, 2021 - Commentary
Opioids, iatrogenic harm and disclosure of medical error.
Citation Text:
Blinderman CD. Opioids, iatrogenic harm and disclosure of medical error. J Pain Symptom Manage. 2010;39(2):309-13. doi:10.1016/j.jpainsymman.2009.11.242.
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psnet.ahrq.gov/issue/reducing-adverse-drug-events-related-opioids-implementation-guide
January 26, 2022 - Toolkit
Reducing Adverse Drug Events Related to Opioids Implementation Guide.
Citation Text:
Reducing Adverse Drug Events Related to Opioids Implementation Guide. Frederickson TW. Gordon DB, De Pinto M, et al. Philadelphia, PA: Society of Hospital Medicine; 2015.
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psnet.ahrq.gov/issue/keeping-nursing-home-residents-and-staff-safe-era-covid-19
November 11, 2020 - Meeting/Conference Proceedings
Keeping Nursing Home Residents and Staff Safe in the Era of COVID-19.
Citation Text:
Keeping Nursing Home Residents and Staff Safe in the Era of COVID-19. National Academy of Medicine. April-June 2020.
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psnet.ahrq.gov/issue/quantifying-distraction-and-interruption-urological-surgery
March 11, 2009 - Study
Quantifying distraction and interruption in urological surgery.
Citation Text:
Healey A, Primus CP, Koutantji M. Quantifying distraction and interruption in urological surgery. Qual Saf Health Care. 2007;16(2):135-9.
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psnet.ahrq.gov/issue/high-costs-unnecessary-care
June 28, 2023 - Commentary
The high costs of unnecessary care.
Citation Text:
Carroll AE. The High Costs of Unnecessary Care. JAMA. 2017;318(18):1748-1749. doi:10.1001/jama.2017.16193.
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psnet.ahrq.gov/issue/lost-sponge-patient-safety-operating-room
January 26, 2022 - Commentary
The lost sponge: patient safety in the operating room.
Citation Text:
Grant-Orser A, Davies P, Singh SS. The lost sponge: patient safety in the operating room. CMAJ . 2012;184(11):1275-1278. doi:10.1503/cmaj.110900.
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psnet.ahrq.gov/issue/using-information-external-errors-signal-clear-and-present-danger
March 14, 2023 - Newspaper/Magazine Article
Using information from external errors to signal a "clear and present danger."
Citation Text:
Using information from external errors to signal a "clear and present danger." ISMP Medication Safety Alert! Acute care edition. February 9, 2017;22:1-5.
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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/taking-aim-infusion-confusion
June 06, 2018 - Commentary
Taking aim at infusion confusion.
Citation Text:
Burdeu G, Crawford R, Van de Vreede M, et al. Taking aim at infusion confusion. J Nurs Care Qual. 2006;21(2):151-159.
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psnet.ahrq.gov/issue/doctors-handovers-hospitals-literature-review
February 29, 2012 - Review
Doctors' handovers in hospitals: a literature review.
Citation Text:
Raduma-Tomàs MA, Flin R, Yule S, et al. Doctors' handovers in hospitals: a literature review. BMJ Qual Saf. 2011;20(2):128-33. doi:10.1136/bmjqs.2009.034389.
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psnet.ahrq.gov/issue/medical-errors-where-are-we-now
September 30, 2020 - Commentary
Medical errors: where are we now?
Citation Text:
Mewshaw MR, White KM, Walrath JM. Medical errors: where are we now? Nurs Manage. 2006;37(10):50-54.
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