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psnet.ahrq.gov/issue/patient-safety-executive-hospital-management-wards-qualitative-study-identifying-factors
March 08, 2023 - Study
Patient safety from executive hospital management to wards: a qualitative study identifying factors influencing implementation.
Citation Text:
Conner T, Unsworth J, Machin A. Patient safety from executive hospital management to wards: a qualitative study identifying factors influen…
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psnet.ahrq.gov/issue/strategies-prevent-missed-nursing-care-international-qualitative-study-based-upon-positive
May 18, 2022 - Study
Strategies to prevent missed nursing care: an international qualitative study based upon a positive deviance approach.
Citation Text:
Longhini J, Papastavrou E, Efstathiou G, et al. Strategies to prevent missed nursing care: an international qualitative study based upon a positive …
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psnet.ahrq.gov/issue/short-and-long-term-effects-electronic-medication-management-system-paediatric-prescribing
August 28, 2024 - Study
Short- and long-term effects of an electronic medication management system on paediatric prescribing errors.
Citation Text:
Westbrook JI, Li L, Raban MZ, et al. Short- and long-term effects of an electronic medication management system on paediatric prescribing errors. NPJ Digit Me…
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psnet.ahrq.gov/node/37494/psn-pdf
January 23, 2008 - Physician-Owned Specialty Hospital's Ability to Manage
Medical Emergencies.
January 23, 2008
Levinson DR. Washington DC: US Department of Health and Human Services, Office of Inspector
General. January 2008, OEI-02-06-00310.
https://psnet.ahrq.gov/issue/physician-owned-specialty-hospitals-ability-manage-medic…
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psnet.ahrq.gov/node/867004/psn-pdf
October 30, 2024 - Critical Radiology Alert Process
October 30, 2024
https://psnet.ahrq.gov/innovation/critical-radiology-alert-process
Summary
Vanderbilt University Medical Center developed an electronic trigger tool that alerts the care team of
unrelated abnormal findings and provides a companion follow-up process, with the goal o…
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psnet.ahrq.gov/node/33606/psn-pdf
December 15, 2024 - Opioid Safety
December 15, 2024
Opioid Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/opioid-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Bac…
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psnet.ahrq.gov/node/36094/psn-pdf
February 12, 2014 - Learning from Disasters: A Management Approach. Third
ed.
February 12, 2014
Toft B, Reynolds S. Leicester, UK: Perpetuity Press Limited; 2005. ISBN: 9781349279029.
https://psnet.ahrq.gov/issue/learning-disasters-management-approach-third-ed
This book provides a discussion of how organizations can learn from failur…
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psnet.ahrq.gov/node/42029/psn-pdf
September 06, 2016 - Management of drug shortages in the perioperative
setting.
September 6, 2016
Murray C, Rycek W, Johnson D, Sifuentes-Tovar F. Pharm Purch Prod. January 2013;10:12.
https://psnet.ahrq.gov/issue/management-drug-shortages-perioperative-setting
This magazine article details how one academic medical center used a colla…
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psnet.ahrq.gov/node/34961/psn-pdf
June 22, 2009 - Improving hospital performance: culture change is not
the answer.
June 22, 2009
Leggat SG, Dwyer J. Improving hospital performance: culture change is not the answer. Healthc Q.
2005;8(2):60-6.
https://psnet.ahrq.gov/issue/improving-hospital-performance-culture-change-not-answer
The authors suggest that people man…
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psnet.ahrq.gov/node/42941/psn-pdf
February 12, 2014 - Risk and Safety Management in Infertility and Assisted
Reproductive Technology.
February 12, 2014
Fertil Steril. 2013;100:1497-1523.
https://psnet.ahrq.gov/issue/risk-and-safety-management-infertility-and-assisted-reproductive-technology
Introduction of assisted reproductive technology has led to new risks i…
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psnet.ahrq.gov/node/33650/psn-pdf
May 01, 2007 - Patient Safety in the United Kingdom: Evolution and
Progress
May 1, 2007
Burnett S, Vincent CA. Patient Safety in the United Kingdom: Evolution and Progress. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
Perspective
The dangers of health care in B…
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psnet.ahrq.gov/issue/findings-and-lessons-improving-management-individuals-complex-health-care-needs-through
October 02, 2013 - Book/Report
Findings and Lessons From the Improving Management of Individuals With Complex Health Care Needs Through Health IT Grant Initiative.
Citation Text:
Findings and Lessons From the Improving Management of Individuals With Complex Health Care Needs Through Health IT Grant Ini…
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psnet.ahrq.gov/issue/defending-never-event
February 14, 2017 - Commentary
Defending a "never event."
Citation Text:
Shepperd JR. Defending a "Never Event". J Healthc Risk Manag. 2017;37(1):17-22. doi:10.1002/jhrm.21277.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/issue/improving-process-while-changing-practice-fmea-and-medication-administration
January 18, 2011 - Commentary
Improving process while changing practice: FMEA and medication administration.
Citation Text:
Riehle MA, Bergeron D, Hyrkäs K. Improving process while changing practice. Nurs Manage. 2009;39(2). doi:10.1097/01.numa.0000310533.54708.38.
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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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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/issue/adopt-strategies-manage-look-alike-andor-sound-alike-medication-name-mix-ups
June 24, 2020 - Newspaper/Magazine Article
Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups.
Citation Text:
Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups. ISMP Medication Safety Alert! Acute care edition. June 2, 2022;27(11):1-4.
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psnet.ahrq.gov/issue/leading-your-organization-high-reliability
August 18, 2021 - Commentary
Leading your organization to high reliability.
Citation Text:
Kemper C, Boyle DK. Leading your organization to high reliability. Nurs Manag. 2009;40(4):14-18. doi:10.1097/01.NUMA.0000349684.24165.68.
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DOI Google Scholar PubMed BibTeX EndNot…
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psnet.ahrq.gov/issue/maximize-benefits-iv-workflow-management-systems-addressing-workarounds-and-errors
May 31, 2017 - Newspaper/Magazine Article
Maximize benefits of IV workflow management systems by addressing workarounds and errors.
Citation Text:
Maximize benefits of IV workflow management systems by addressing workarounds and errors. ISMP Medication Safety Alert! Acute care edition. September 7, 20…
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psnet.ahrq.gov/issue/clinical-decision-support-and-malpractice-risk
September 24, 2017 - Commentary
Clinical decision support and malpractice risk.
Citation Text:
Greenberg MD, Ridgely MS. Clinical Decision Support and Malpractice Risk. JAMA. 2011;306(1). doi:10.1001/jama.2011.929.
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psnet.ahrq.gov/issue/where-should-patient-safety-be-installed
October 05, 2022 - Commentary
Where should patient safety be installed?
Citation Text:
Sine DM, Paull D. Where should patient safety be installed? J Healthc Risk Manag. 2017;37(3):14-17. doi:10.1002/jhrm.21285.
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