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  1. The differences between human error, at-risk behavior, and reckless behavior are key to a just culture. | PSNet

    psnet.ahrq.gov/issue/differences-between-human-error-risk-behavior-and-reckless-behavior-are-key-just-culture
    September 23, 2020 - Newspaper/Magazine Article The differences between human error, at-risk behavior, and reckless behavior are key to a just culture. Citation Text: The differences between human error, at-risk behavior, and reckless behavior are key to a just culture. ISMP Medication Safety Alert! Acute Ca…

  2. Medication errors and adverse drug events in pediatric inpatients. | PSNet

    psnet.ahrq.gov/issue/medication-errors-and-adverse-drug-events-pediatric-inpatients
    January 19, 2011 - Study Classic Medication errors and adverse drug events in pediatric inpatients. Citation Text: Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114-20. Copy Citation Format: …

  3. How are medication errors defined? A systematic literature review of definitions and characteristics. | PSNet

    psnet.ahrq.gov/issue/how-are-medication-errors-defined-systematic-literature-review-definitions-and
    May 30, 2012 - Review How are medication errors defined? A systematic literature review of definitions and characteristics. Citation Text: Lisby M, Nielsen LP, Brock B, et al. How are medication errors defined? A systematic literature review of definitions and characteristics. International Journal f…

  4. Increasing reporting of adverse events to improve the educational value of the morbidity and mortality conference. | PSNet

    psnet.ahrq.gov/issue/increasing-reporting-adverse-events-improve-educational-value-morbidity-and-mortality
    February 04, 2016 - Study Increasing reporting of adverse events to improve the educational value of the morbidity and mortality conference. Citation Text: McVeigh TP, Waters PS, Murphy R, et al. Increasing reporting of adverse events to improve the educational value of the morbidity and mortality confere…

  5. A prospective cohort study of medication reconciliation using pharmacy technicians in the emergency department to reduce medication errors among admitted patients. | PSNet

    psnet.ahrq.gov/issue/prospective-cohort-study-medication-reconciliation-using-pharmacy-technicians-emergency
    July 01, 2019 - Study A prospective cohort study of medication reconciliation using pharmacy technicians in the emergency department to reduce medication errors among admitted patients. Citation Text: Cater SW, Luzum M, Serra AE, et al. A prospective cohort study of medication reconciliation using pharm…

  6. Implementation of bar-code medication administration to reduce patient harm. | PSNet

    psnet.ahrq.gov/issue/implementation-bar-code-medication-administration-reduce-patient-harm
    September 23, 2020 - Study Implementation of bar-code medication administration to reduce patient harm. Citation Text: Thompson KM, Swanson KM, Cox DL, et al. Implementation of Bar-Code Medication Administration to Reduce Patient Harm. Mayo Clin Proc Innov Qual Outcomes. 2018;2(4):342-351. doi:10.1016/j.mayo…

  7. Hospital workload and adverse events. | PSNet

    psnet.ahrq.gov/issue/hospital-workload-and-adverse-events
    August 31, 2011 - Study Classic Hospital workload and adverse events. Citation Text: Weissman JS, Rothschild JM, Bendavid E, et al. Hospital workload and adverse events. Med Care. 2007;45(5):448-55. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML…

  8. Types and patterns of safety concerns in home care: client and family caregiver perspectives. | PSNet

    psnet.ahrq.gov/issue/types-and-patterns-safety-concerns-home-care-client-and-family-caregiver-perspectives
    December 29, 2014 - Study Types and patterns of safety concerns in home care: client and family caregiver perspectives. Citation Text: Tong CE, Sims-Gould J, Martin-Matthews A. Types and patterns of safety concerns in home care: client and family caregiver perspectives. Int J Qual Health Care. 2016;28(2):21…

  9. Interventions to improve hand hygiene compliance in the ICU: a systematic review. | PSNet

    psnet.ahrq.gov/issue/interventions-improve-hand-hygiene-compliance-icu-systematic-review
    January 23, 2019 - Review Interventions to improve hand hygiene compliance in the ICU: a systematic review. Citation Text: Lydon S, Power M, McSharry J, et al. Interventions to Improve Hand Hygiene Compliance in the ICU. Crit Care Med. 2017;45(11). doi:10.1097/ccm.0000000000002691. Copy Citation Form…

  10. ACR guidance document on MR safe practices: updates and critical information 2019. | PSNet

    psnet.ahrq.gov/issue/acr-guidance-document-mr-safe-practices-updates-and-critical-information-2019
    June 22, 2022 - Commentary ACR guidance document on MR safe practices: updates and critical information 2019. Citation Text: ACR guidance document on MR safe practices: updates and critical information 2019. ACR Committee on MR Safety, Greenberg TD, Hoff MN, Gilk TB, et al. J Magn Reson Imaging. 20…

  11. Healthcare scandals and the failings of doctors: do official inquiries hold the profession to account? | PSNet

    psnet.ahrq.gov/issue/healthcare-scandals-and-failings-doctors-do-official-inquiries-hold-profession-account
    November 13, 2019 - Review Healthcare scandals and the failings of doctors: do official inquiries hold the profession to account? Citation Text: Mannion R, Davies H, Powell M, et al. Healthcare scandals and the failings of doctors. J Health Organ Manag. 2019;33(2):221-240. doi:10.1108/JHOM-04-2018-0126. C…

  12. Learning from the best. | PSNet

    psnet.ahrq.gov/issue/learning-best
    February 22, 2023 - Newspaper/Magazine Article Learning from the best. Citation Text: Grantham D. Learning from the best. Behavioral healthcare. 2010;30(4):22-4. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cit…

  13. Patient Safety Learning. | PSNet

    psnet.ahrq.gov/issue/patient-safety-learning
    January 12, 2022 - Multi-use Website Patient Safety Learning. Citation Text: Patient Safety Learning. Patient Safety Learning. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …

  14. Learning From Mistakes. | PSNet

    psnet.ahrq.gov/issue/learning-mistakes
    March 28, 2018 - July 19, 2023 Unlocking Solutions in Imaging: Working Together to Learn from Failings

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43253/psn-pdf
    May 01, 2015 - interim-report-review-vhas-patient-wait-times-scheduling-practices-and-alleged-patient-deaths https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation

  16. In Conversation With… Susan E. Skochelak, MD, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
    February 01, 2019 - RW : How has the drive to rethink the content of the curriculum (what learners needed to learn) synced … the health care system around bringing these concepts front and center into the way in which students learn … We want to learn from you, we want to evaluate together, and we want to rapidly disseminate best practices … We're worried they might feel like why did I learn all of that or why did I get invested in all of that … a state we refer to as being a systems citizen.( 6-8 ) For such a paradigm shift, providers need to learn

  17. Building a learning organization. | PSNet

    psnet.ahrq.gov/issue/building-learning-organization
    June 16, 2011 - Study Classic Building a learning organization. Citation Text: Garvin DA. Building a learning organization. Harv Bus Rev. 1993;71(4):78-91. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

  18. Learning Health Systems | PSNet

    psnet.ahrq.gov/issue/learning-health-systems
    December 24, 2008 - Multi-use Website Learning Health Systems Citation Text: Learning Health Systems Agency for Health Research and Quality. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …

  19. Shifting the learning curve. | PSNet

    psnet.ahrq.gov/issue/shifting-learning-curve
    March 09, 2009 - Commentary Shifting the learning curve. Citation Text: Reynolds T, Kong M-L. Shifting the learning curve. BMJ. 2010;341:c6260. doi:10.1136/bmj.c6260. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  20. Learning from Investigations. | PSNet

    psnet.ahrq.gov/issue/learning-investigations
    July 28, 2013 - Book/Report Learning from Investigations. Citation Text: Learning from Investigations. Commission for Healthcare Audit and Inspection. London, England; Healthcare Commission: 2008. ISBN 9781845621636. Copy Citation Save Save to your library Print Downlo…
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