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  1. Health IT Safe Practices for Closing the Loop. | PSNet

    psnet.ahrq.gov/issue/health-it-safe-practices-closing-loop
    March 10, 2021 - Toolkit Health IT Safe Practices for Closing the Loop. Citation Text: Health IT Safe Practices for Closing the Loop. Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; August 2018. Copy Citation Save Save to your library Print Download…

  2. Medication Overload: America's Other Drug Problem. | PSNet

    psnet.ahrq.gov/issue/medication-overload-americas-other-drug-problem
    April 01, 2020 - Book/Report Medication Overload: America's Other Drug Problem. Citation Text: Medication Overload: America's Other Drug Problem. Brownlee S; Garber J. Brookline, MA: Lown Institute; 2019. Copy Citation Save Save to your library Print Download PDF …

  3. Adherence to a medication safety protocol: current practice for labeling medications and solutions on the sterile field. | PSNet

    psnet.ahrq.gov/issue/adherence-medication-safety-protocol-current-practice-labeling-medications-and-solutions
    July 19, 2023 - Study Adherence to a medication safety protocol: current practice for labeling medications and solutions on the sterile field. Citation Text: Brown-Brumfield D, DeLeon A. Adherence to a medication safety protocol: current practice for labeling medications and solutions on the sterile f…

  4. Optimizing Health IT for Safe Integration of Behavioral Health and Primary Care. | PSNet

    psnet.ahrq.gov/issue/optimizing-health-it-safe-integration-behavioral-health-and-primary-care
    March 10, 2021 - Book/Report Optimizing Health IT for Safe Integration of Behavioral Health and Primary Care. Citation Text: Optimizing Health IT for Safe Integration of Behavioral Health and Primary Care. Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021. Copy Cita…

  5. Start the new year off right by preventing these top 10 medication errors and hazards. | PSNet

    psnet.ahrq.gov/issue/start-new-year-right-preventing-these-top-10-medication-errors-and-hazards
    February 09, 2022 - Newspaper/Magazine Article Start the new year off right by preventing these top 10 medication errors and hazards. Citation Text: Start the new year off right by preventing these top 10 medication errors and hazards. ISMP Medication Safety Alert! Acute care edition. January 16, 2020;26(2)…

  6. Circle Up Training. | PSNet

    psnet.ahrq.gov/issue/circle-training
    February 22, 2023 - Multi-use Website Circle Up Training. Citation Text: Circle Up Training. Center for Medical Simulation. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May …

  7. Overconfidence as a cause of diagnostic error in medicine. | PSNet

    psnet.ahrq.gov/issue/overconfidence-cause-diagnostic-error-medicine
    July 30, 2014 - Review Overconfidence as a cause of diagnostic error in medicine. Citation Text: Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121(5 Suppl):S2-S23. doi:10.1016/j.amjmed.2008.01.001. Copy Citation Format: DOI Google Scholar…

  8. Cognitive Systems Engineering in Health Care. | PSNet

    psnet.ahrq.gov/issue/cognitive-systems-engineering-health-care
    October 11, 2016 - Book/Report Cognitive Systems Engineering in Health Care. Citation Text: Cognitive Systems Engineering in Health Care. Bisantz AM, Burns CM, Fairbanks RJ, eds. Boca Raton, FL: CRC Press; 2014. ISBN: 9781466587960. Copy Citation Save Save to your library Prin…

  9. Wide heart monitor use tied to missed alarms. | PSNet

    psnet.ahrq.gov/issue/wide-heart-monitor-use-tied-missed-alarms
    July 19, 2023 - Newspaper/Magazine Article Wide heart monitor use tied to missed alarms. Citation Text: Funk M, Winkler CG, May JL, et al. Unnecessary arrhythmia monitoring and underutilization of ischemia and QT interval monitoring in current clinical practice: baseline results of the Practical Use o…

  10. Promoting civility in the OR: an ethical imperative. | PSNet

    psnet.ahrq.gov/issue/promoting-civility-or-ethical-imperative
    September 12, 2016 - Commentary Promoting civility in the OR: an ethical imperative. Citation Text: Clark CM, Kenski D. Promoting Civility in the OR: An Ethical Imperative. AORN J. 2017;105(1):60-66. doi:10.1016/j.aorn.2016.10.019. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote …

  11. Understanding the root cause analysis process to increase safety event reporting. | PSNet

    psnet.ahrq.gov/issue/understanding-root-cause-analysis-process-increase-safety-event-reporting
    August 08, 2018 - Commentary Understanding the root cause analysis process to increase safety event reporting. Citation Text: Dudley KA. Understanding the root cause analysis process to increase safety event reporting. AORN J. 2023;117(6):399-402. doi:10.1002/aorn.13935. Copy Citation Format: …

  12. Creating safety culture on nursing units: human performance and organizational system factors that make a difference. | PSNet

    psnet.ahrq.gov/issue/creating-safety-culture-nursing-units-human-performance-and-organizational-system-factors
    May 29, 2013 - Study Creating safety culture on nursing units: human performance and organizational system factors that make a difference. Citation Text: Moody RF, Pesut DJ, Harrington CF. Creating Safety Culture on Nursing Units. J Patient Saf. 2008;2(4). doi:10.1097/01.jps.0000242978.40424.24. Co…

  13. Mean girls of the ER: the alarming nurse culture of bullying and hazing. | PSNet

    psnet.ahrq.gov/issue/mean-girls-er-alarming-nurse-culture-bullying-and-hazing
    November 01, 2017 - Newspaper/Magazine Article Mean girls of the ER: the alarming nurse culture of bullying and hazing. Citation Text: Mean girls of the ER: the alarming nurse culture of bullying and hazing. Robbins A. Good Housekeeping. May 20, 2016. Copy Citation Save Save to you…

  14. Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes. | PSNet

    psnet.ahrq.gov/issue/two-effective-initiatives-c-suite-leaders-improve-medication-safety-and-reliability-outcomes
    March 14, 2023 - Newspaper/Magazine Article Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes. Citation Text: Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes. ISMP Medication Safety Alert! …

  15. Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error | PSNet

    psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error
    February 10, 2021 - Newspaper/Magazine Article Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error Citation Text: Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2. …

  16. Fatal Solutions: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture. | PSNet

    psnet.ahrq.gov/issue/fatal-solutions-how-healthcare-system-used-tragedy-transform-itself-and-redefine-just-culture
    May 16, 2019 - Book/Report Fatal Solutions: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture. Citation Text: Fatal Solutions: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture. Davies JM, Steinke C, Flemons WW. New York, NY: Productivit…

  17. Workarounds are routinely used by nurses—but are they ethical? | PSNet

    psnet.ahrq.gov/issue/workarounds-are-routinely-used-nurses-are-they-ethical
    October 27, 2016 - Commentary Workarounds are routinely used by nurses—but are they ethical? Citation Text: Berlinger N. Workarounds Are Routinely Used by Nurses-But Are They Ethical? Am J Nurs. 2017;117(10):53-55. doi:10.1097/01.NAJ.0000525875.82101.b7. Copy Citation Format: DOI Google Schol…

  18. A secondary care nursing perspective on medication administration safety. | PSNet

    psnet.ahrq.gov/issue/secondary-care-nursing-perspective-medication-administration-safety
    July 23, 2010 - Study A secondary care nursing perspective on medication administration safety. Citation Text: McBride-Henry K, Foureur M. A secondary care nursing perspective on medication administration safety. J Adv Nurs. 2007;60(1):58-66. Copy Citation Format: Google Scholar PubMed B…

  19. Challenges and opportunities of patient safety event reporting. | PSNet

    psnet.ahrq.gov/issue/challenges-and-opportunities-patient-safety-event-reporting
    June 23, 2021 - Commentary Challenges and opportunities of patient safety event reporting. Citation Text: Gong Y. Challenges and opportunities of patient safety event reporting. Stud Health Technol Inform. 2022;291:133-150. doi:10.3233/shti220014. Copy Citation Format: DOI Google Scholar B…

  20. System-related and cognitive errors in laboratory medicine. | PSNet

    psnet.ahrq.gov/issue/system-related-and-cognitive-errors-laboratory-medicine
    December 21, 2016 - Commentary System-related and cognitive errors in laboratory medicine. Citation Text: Plebani M. System-related and cognitive errors in laboratory medicine. Diagnosis (Berl). 2018;5(4):191-196. doi:10.1515/dx-2018-0085. Copy Citation Format: DOI Google Scholar PubMed BibTeX…
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