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  1. Optimizing Pediatric Patient Safety in the Emergency Care Setting. | PSNet

    psnet.ahrq.gov/issue/optimizing-pediatric-patient-safety-emergency-care-setting
    March 15, 2023 - Organizational Policy/Guidelines Optimizing Pediatric Patient Safety in the Emergency Care Setting. Citation Text: Joseph MM, Mahajan P, Snow SK, et al. Optimizing Pediatric Patient Safety in the Emergency Care Setting. Pediatrics. 2022;150(5):e2022059673. doi:10.1542/peds.2022-059673. …

  2. The need for closed-loop systems for management of abnormal test results. | PSNet

    psnet.ahrq.gov/issue/need-closed-loop-systems-management-abnormal-test-results
    May 20, 2019 - Study The need for closed-loop systems for management of abnormal test results. Citation Text: Zuccotti G, Samal L, Maloney FL, et al. The Need for Closed-Loop Systems for Management of Abnormal Test Results. Ann Intern Med. 2018;168(11):820-821. doi:10.7326/M17-2425. Copy Citation …

  3. Improving medication management through the redesign of the hospital code cart medication drawer. | PSNet

    psnet.ahrq.gov/issue/improving-medication-management-through-redesign-hospital-code-cart-medication-drawer
    October 31, 2018 - Study Improving medication management through the redesign of the hospital code cart medication drawer. Citation Text: Rousek JB, Hallbeck MS. Improving Medication Management Through the Redesign of the Hospital Code Cart Medication Drawer. Human Factors: The Journal of the Human Facto…

  4. Americans' Experiences With Medical Errors and Views on Patient Safety. | PSNet

    psnet.ahrq.gov/issue/americans-experiences-medical-errors-and-views-patient-safety
    January 06, 2015 - Book/Report Classic Americans' Experiences With Medical Errors and Views on Patient Safety. Citation Text: Americans' Experiences With Medical Errors and Views on Patient Safety. Chicago, IL: NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute;…

  5. Poor resident–attending intraoperative communication may compromise patient safety. | PSNet

    psnet.ahrq.gov/issue/poor-resident-attending-intraoperative-communication-may-compromise-patient-safety
    September 23, 2020 - Study Poor resident–attending intraoperative communication may compromise patient safety. Citation Text: Belyansky I, Martin TR, Prabhu AS, et al. Poor resident-attending intraoperative communication may compromise patient safety. J Surg Res. 2011;171(2):386-94. doi:10.1016/j.jss.2011.…

  6. Intravenous smart pumps: usability issues, intravenous medication administration error, and patient safety. | PSNet

    psnet.ahrq.gov/issue/intravenous-smart-pumps-usability-issues-intravenous-medication-administration-error-and
    July 31, 2019 - Review Intravenous smart pumps: usability issues, intravenous medication administration error, and patient safety. Citation Text: Giuliano KK. Intravenous Smart Pumps: Usability Issues, Intravenous Medication Administration Error, and Patient Safety. Crit Care Nurs Clin North Am. 2018;30…

  7. Frequency of medication administration timing error in hospitals: a systematic review. | PSNet

    psnet.ahrq.gov/issue/frequency-medication-administration-timing-error-hospitals-systematic-review
    March 15, 2023 - Review Frequency of medication administration timing error in hospitals: a systematic review. Citation Text: Pullam T, Russell CL, White-Lewis S. Frequency of medication administration timing error in hospitals: a systematic review. J Nurs Care Qual. 2023;38(2):126-133. doi:10.1097/ncq.0…

  8. A tool for the concise analysis of patient safety incidents. | PSNet

    psnet.ahrq.gov/issue/tool-concise-analysis-patient-safety-incidents
    August 09, 2018 - Study A tool for the concise analysis of patient safety incidents. Citation Text: Pham JC, Hoffman C, Popescu I, et al. A Tool for the Concise Analysis of Patient Safety Incidents. Jt Comm J Qual Patient Saf. 2016;42(1):26-33. Copy Citation Format: Google Scholar PubMed Bib…

  9. Nurse burnout predicts self-reported medication administration errors in acute care hospitals. | PSNet

    psnet.ahrq.gov/issue/nurse-burnout-predicts-self-reported-medication-administration-errors-acute-care-hospitals
    August 25, 2021 - Study Nurse burnout predicts self-reported medication administration errors in acute care hospitals. Citation Text: Montgomery AP, Azuero A, Baernholdt MB, et al. Nurse burnout predicts self-reported medication administration errors in acute care hospitals. J Healthc Qual. 2020;43(1):13…

  10. I-PASS mentored implementation handoff curriculum: champion training materials. | PSNet

    psnet.ahrq.gov/issue/i-pass-mentored-implementation-handoff-curriculum-champion-training-materials
    November 16, 2022 - Commentary I-PASS mentored implementation handoff curriculum: champion training materials. Citation Text: O'Toole JK, Starmer AJ, Calaman S, et al. I-PASS Mentored Implementation Handoff Curriculum: Champion Training Materials. MedEdPORTAL. 2019;15:10794. doi:10.15766/mep_2374-8265.10794…

  11. Opportunities to mine EHRs for malpractice risk management and patient safety. | PSNet

    psnet.ahrq.gov/issue/opportunities-mine-ehrs-malpractice-risk-management-and-patient-safety
    October 28, 2020 - Commentary Opportunities to mine EHRs for malpractice risk management and patient safety. Citation Text: Adler-Milstein J, Sarkar U, Wachter RM. Opportunities to mine EHRs for malpractice risk management and patient safety. J Patient Saf Risk Manag. 2022;27(4):160-162. doi:10.1177/251604…

  12. Reconciling medications at admission: safe practice recommendations and implementation strategies. | PSNet

    psnet.ahrq.gov/issue/reconciling-medications-admission-safe-practice-recommendations-and-implementation-strategies
    January 02, 2017 - Study Reconciling medications at admission: safe practice recommendations and implementation strategies. Citation Text: Rogers G, Alper E, Brunelle D, et al. Reconciling Medications at Admission: Safe Practice Recommendations and Implementation Strategies. Jt Comm J Qual Patient Saf. 2…

  13. Understanding factors influencing safety and team functionality at operative vaginal birth through multidisciplinary perspectives: a mixed methods study. | PSNet

    psnet.ahrq.gov/issue/understanding-factors-influencing-safety-and-team-functionality-operative-vaginal-birth
    September 01, 2016 - Study Understanding factors influencing safety and team functionality at operative vaginal birth through multidisciplinary perspectives: a mixed methods study. Citation Text: Skinner SM, Kippen E, Rolnik DL, et al. Understanding factors influencing safety and team functionality at operat…

  14. The wrong patient. | PSNet

    psnet.ahrq.gov/issue/wrong-patient
    December 23, 2008 - Commentary Classic The wrong patient. Citation Text: Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136(11):826-833. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  15. Walking the tightrope: communicating overdiagnosis in modern healthcare. | PSNet

    psnet.ahrq.gov/issue/walking-tightrope-communicating-overdiagnosis-modern-healthcare
    September 23, 2020 - Commentary Walking the tightrope: communicating overdiagnosis in modern healthcare. Citation Text: McCaffery KJ, Jansen J, Scherer LD, et al. Walking the tightrope: communicating overdiagnosis in modern healthcare. BMJ. 2016;352:i348. doi:10.1136/bmj.i348. Copy Citation Format: …

  16. Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes. | PSNet

    psnet.ahrq.gov/issue/interdisciplinary-icu-cardiac-arrest-debriefing-improves-survival-outcomes
    September 02, 2020 - Study Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes. Citation Text: Wolfe H, Zebuhr C, Topjian AA, et al. Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes*. Crit Care Med. 2014;42(7):1688-95. doi:10.1097/CCM.0000000000000327. Copy …

  17. Medication errors in emergency departments: a systematic review and meta-analysis of prevalence and severity | PSNet

    psnet.ahrq.gov/issue/medication-errors-emergency-departments-systematic-review-and-meta-analysis-prevalence-and
    April 02, 2014 - Review Medication errors in emergency departments: a systematic review and meta-analysis of prevalence and severity Citation Text: Nguyen PTL, Phan TAT, Vo VBN, et al. Medication errors in emergency departments: a systematic review and meta-analysis of prevalence and severity. Int J Clin…

  18. Crossing the Global Quality Chasm: Improving Health Care Worldwide. | PSNet

    psnet.ahrq.gov/issue/crossing-global-quality-chasm-improving-health-care-worldwide
    June 15, 2011 - Book/Report Classic Crossing the Global Quality Chasm: Improving Health Care Worldwide. Citation Text: Crossing the Global Quality Chasm: Improving Health Care Worldwide. Committee on Improving the Quality of Health Care Globally. National Academies of Sciences,…

  19. Preventing medication errors in transitions of care: a patient case approach. | PSNet

    psnet.ahrq.gov/issue/preventing-medication-errors-transitions-care-patient-case-approach
    October 17, 2012 - Review Preventing medication errors in transitions of care: a patient case approach. Citation Text: Johnson A, Guirguis E, Grace Y. Preventing medication errors in transitions of care: A patient case approach. J Am Pharm Assoc (2003). 2015;55(2):e264-276. doi:10.1331/JAPhA.2015.15509. …

  20. Current surgical instrument labeling techniques may increase the risk of unintentionally retained foreign objects: a hypothesis. | PSNet

    psnet.ahrq.gov/issue/current-surgical-instrument-labeling-techniques-may-increase-risk-unintentionally-retained
    February 08, 2012 - Commentary Current surgical instrument labeling techniques may increase the risk of unintentionally retained foreign objects: a hypothesis. Citation Text: Ipaktchi K, Kolnik A, Messina M, et al. Current surgical instrument labeling techniques may increase the risk of unintentionally ret…
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