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  1. Using snowball sampling method with nurses to understand medication administration errors. | PSNet

    psnet.ahrq.gov/issue/using-snowball-sampling-method-nurses-understand-medication-administration-errors
    August 02, 2011 - Study Using snowball sampling method with nurses to understand medication administration errors. Citation Text: Sheu S-J, Wei I-L, Chen C-H, et al. Using snowball sampling method with nurses to understand medication administration errors. J Clin Nurs. 2009;18(4):559-69. doi:10.1111/j.1…

  2. Wrong administration route of medications in the domestic setting: a review of an underestimated public health topic. | PSNet

    psnet.ahrq.gov/issue/wrong-administration-route-medications-domestic-setting-review-underestimated-public-health
    December 15, 2021 - Review Wrong administration route of medications in the domestic setting: a review of an underestimated public health topic. Citation Text: Gualano MR, Lo Moro G, Voglino G, et al. Wrong administration route of medications in the domestic setting: a review of an underestimated public hea…

  3. Medication-prescribing errors in a teaching hospital: a 9-year experience. | PSNet

    psnet.ahrq.gov/issue/medication-prescribing-errors-teaching-hospital-9-year-experience
    February 10, 2011 - Study Classic Medication-prescribing errors in a teaching hospital: a 9-year experience. Citation Text: Lesar TS, Lomaestro BM, Pohl H. Medication-prescribing errors in a teaching hospital. A 9-year experience. Arch Intern Med. 1997;157(14):1569-76. Copy Cit…

  4. Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly. | PSNet

    psnet.ahrq.gov/issue/assisting-beginners-root-cause-analysis-operations-analysis-and-recommendations-regarding
    June 08, 2022 - Commentary Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly. Citation Text: Tsuchiya H. Assisting beginners in root cause analysis operations: analysis and recommendations regarding …

  5. The impact of the 80-hour work week on appropriate resident case coverage. | PSNet

    psnet.ahrq.gov/issue/impact-80-hour-work-week-appropriate-resident-case-coverage
    June 18, 2008 - Study The impact of the 80-hour work week on appropriate resident case coverage. Citation Text: Shin S, Britt R, Doviak M, et al. The Impact of the 80-Hour Work Week on Appropriate Resident Case Coverage. Journal of Surgical Research. 2009;162(1). doi:10.1016/j.jss.2009.12.003. Copy …

  6. Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system. | PSNet

    psnet.ahrq.gov/issue/barriers-and-success-factors-implementation-multi-site-prospective-adverse-event-surveillance
    November 15, 2017 - Study Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system. Citation Text: Backman C, Forster AJ, Vanderloo S. Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system. Int…

  7. Lost opportunities: how physicians communicate about medical errors. | PSNet

    psnet.ahrq.gov/issue/lost-opportunities-how-physicians-communicate-about-medical-errors
    July 10, 2008 - Study Lost opportunities: how physicians communicate about medical errors. Citation Text: Garbutt J, Waterman AD, Kapp JM, et al. Lost Opportunities: How Physicians Communicate About Medical Errors. Health Aff (Millwood). 2008;27(1):246-255. doi:10.1377/hlthaff.27.1.246. Copy Citati…

  8. Identifying barriers to the effective use of clinical reminders: bootstrapping multiple methods. | PSNet

    psnet.ahrq.gov/issue/identifying-barriers-effective-use-clinical-reminders-bootstrapping-multiple-methods
    March 11, 2011 - Study Identifying barriers to the effective use of clinical reminders: bootstrapping multiple methods. Citation Text: Patterson ES, Doebbeling BN, Fung CH, et al. Identifying barriers to the effective use of clinical reminders: bootstrapping multiple methods. J Biomed Inform. 2005;38(3):…

  9. Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. | PSNet

    psnet.ahrq.gov/issue/proficiency-based-virtual-reality-training-significantly-reduces-error-rate-residents-during
    November 13, 2009 - Study Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. Citation Text: Ahlberg G, Enochsson L, Gallagher AG, et al. Proficiency-based virtual reality training significantly reduces the err…

  10. Developing standardized "receiver-driven" handoffs between referring providers and the emergency department: results of a multidisciplinary needs assessment. | PSNet

    psnet.ahrq.gov/issue/developing-standardized-receiver-driven-handoffs-between-referring-providers-and-emergency
    June 03, 2020 - Study Developing standardized "receiver-driven" handoffs between referring providers and the emergency department: results of a multidisciplinary needs assessment. Citation Text: Huth K, Stack AM, Chi G, et al. Developing Standardized "Receiver-Driven" Handoffs Between Referring Provider…

  11. How different countries respond to adverse events whilst patients' rights are protected. | PSNet

    psnet.ahrq.gov/issue/how-different-countries-respond-adverse-events-whilst-patients-rights-are-protected
    December 11, 2024 - Study How different countries respond to adverse events whilst patients' rights are protected. Citation Text: Gil-Hernández E, Carrillo I, Tumelty M-E, et al. How different countries respond to adverse events whilst patients’ rights are protected. Med Sci Law. 2024;64(2):96-112. doi:10.1…

  12. Why an open disclosure procedure is and is not followed after an avoidable adverse event. | PSNet

    psnet.ahrq.gov/issue/why-open-disclosure-procedure-and-not-followed-after-avoidable-adverse-event
    August 11, 2021 - Study Why an open disclosure procedure is and is not followed after an avoidable adverse event. Citation Text: Carrillo I, Mira JJ, Guilabert M, et al. Why an open disclosure procedure is and is not followed after an avoidable adverse event. J Patient Saf. 2021;17(6):e529-e533. doi:10.10…

  13. Physician patient communication failure facilitates medication errors in older polymedicated patients with multiple comorbidities. | PSNet

    psnet.ahrq.gov/issue/physician-patient-communication-failure-facilitates-medication-errors-older-polymedicated
    November 02, 2010 - Study Physician patient communication failure facilitates medication errors in older polymedicated patients with multiple comorbidities. Citation Text: Mira JJ, Orozco-Beltrán D, Pérez-Jover V, et al. Physician patient communication failure facilitates medication errors in older polyme…

  14. Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia. | PSNet

    psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-diagnosed-prostate-cancer-hampton-va-medical
    July 26, 2023 - Book/Report Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia. Citation Text: Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in V…

  15. How health care systems let our patients down: a systematic review into suicide deaths. | PSNet

    psnet.ahrq.gov/issue/how-health-care-systems-let-our-patients-down-systematic-review-suicide-deaths
    October 19, 2022 - Review How health care systems let our patients down: a systematic review into suicide deaths. Citation Text: Wyder M, Ray MK, Roennfeldt H, et al. How health care systems let our patients down: a systematic review into suicide deaths. Int J Qual Health Care. 2020;32(5):285-291. doi:10.1…

  16. Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature. | PSNet

    psnet.ahrq.gov/issue/explanation-and-elaboration-squire-standards-quality-improvement-reporting-excellence
    November 18, 2016 - Commentary Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature. Citation Text: Goodman D, Ogrinc G, Davies L, et al. Explanation and elaboration of the S…

  17. Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds. | PSNet

    psnet.ahrq.gov/issue/changes-safety-and-teamwork-climate-after-adding-structured-observations-patient-safety
    August 20, 2018 - Study Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds. Citation Text: Klimmeck S, Sexton B, Schwendimann R. Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds. Jt Comm J Qual Pa…

  18. Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings: a scoping review and thematic analysis. | PSNet

    psnet.ahrq.gov/issue/health-professionals-experiences-whistleblowing-maternal-and-newborn-healthcare-settings
    November 02, 2010 - Review Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings: a scoping review and thematic analysis. Citation Text: Capper T, Ferguson B, Muurlink O. Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings…

  19. Accurate measurement in California's safety-net health systems has gaps and barriers. | PSNet

    psnet.ahrq.gov/issue/accurate-measurement-californias-safety-net-health-systems-has-gaps-and-barriers
    April 04, 2018 - Study Accurate measurement in California's safety-net health systems has gaps and barriers. Citation Text: Khoong EC, Cherian R, Rivadeneira NA, et al. Accurate Measurement In California's Safety-Net Health Systems Has Gaps And Barriers. Health Aff (Millwood). 2018;37(11):1760-1769. doi:…

  20. Factors associated with malpractice claim payout: an analysis of closed emergency department claims. | PSNet

    psnet.ahrq.gov/issue/factors-associated-malpractice-claim-payout-analysis-closed-emergency-department-claims
    May 18, 2022 - Study Factors associated with malpractice claim payout: an analysis of closed emergency department claims. Citation Text: Gupta K, Szymonifka J, Rivadeneira NA, et al. Factors associated with malpractice claim payout: an analysis of closed emergency department claims. Jt Comm J Qual Pati…
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