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VHA's movement for change: implementing high-reliability principles and practices. | PSNet

psnet.ahrq.gov/issue/vhas-movement-change-implementing-high-reliability-principles-and-practices

August 21, 2024 - Commentary VHA's movement for change: implementing high-reliability principles and practices. Citation Text: Cox GR, Starr LM. VHA's movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68(3):151-157. doi:10.1097/jhm-d-23-00056. Copy Citati…

Patient safety and suicide prevention in mental health services: time for a new paradigm? | PSNet

psnet.ahrq.gov/issue/patient-safety-and-suicide-prevention-mental-health-services-time-new-paradigm

April 19, 2023 - Commentary Patient safety and suicide prevention in mental health services: time for a new paradigm? Citation Text: Quinlivan L, Littlewood DL, Webb RT, et al. Patient safety and suicide prevention in mental health services: time for a new paradigm? J Mental Health. 2020;29(1):1-5. doi…

Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center. | PSNet

psnet.ahrq.gov/issue/mislabeled-units-umbilical-cord-blood-detected-quality-assurance-program-transplantation

October 19, 2022 - Study Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center. Citation Text: McCullough JS, McKenna D, Kadidlo D, et al. Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation cente…

Care at the point of impact: insights into the second-victim experience. | PSNet

psnet.ahrq.gov/issue/care-point-impact-insights-second-victim-experience

January 03, 2017 - Commentary Care at the point of impact: insights into the second-victim experience. Citation Text: Scott SD, McCoig MM. Care at the point of impact: Insights into the second-victim experience. J Healthc Risk Manag. 2016;35(4):6-13. doi:10.1002/jhrm.21218. Copy Citation Format: …

Enhancing pediatric safety: assessing and improving resident competency in life-threatening events with a computer-based interactive resuscitation tool. | PSNet

psnet.ahrq.gov/issue/enhancing-pediatric-safety-assessing-and-improving-resident-competency-life-threatening

December 14, 2016 - Study Enhancing pediatric safety: assessing and improving resident competency in life-threatening events with a computer-based interactive resuscitation tool. Citation Text: Lerner C, Gaca AM, Frush DP, et al. Enhancing pediatric safety: assessing and improving resident competency in l…

Overriding of drug safety alerts in computerized physician order entry. | PSNet

psnet.ahrq.gov/issue/overriding-drug-safety-alerts-computerized-physician-order-entry

March 04, 2011 - Review Overriding of drug safety alerts in computerized physician order entry. Citation Text: van der Sijs H, Aarts J, Vulto A, et al. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc. 2006;13(2):138-47. Copy Citation Format: G…

Lost in translation: medication labeling for immigrant families. | PSNet

psnet.ahrq.gov/issue/lost-translation-medication-labeling-immigrant-families

May 31, 2017 - Commentary Lost in translation: medication labeling for immigrant families. Citation Text: Smith MCJ, Yin S, Sanders LM. Lost in translation: Medication labeling for immigrant families. J Am Pharm Assoc (2003). 2016;56(6):677-679. doi:10.1016/j.japh.2016.07.002. Copy Citation Forma…

The relationship between safety climate and safety performance: a review. | PSNet

psnet.ahrq.gov/issue/relationship-between-safety-climate-and-safety-performance-review

February 03, 2021 - Review The relationship between safety climate and safety performance: a review. Citation Text: Syed-Yahya SNN, Idris MA, Noblet AJ. The relationship between safety climate and safety performance: a review. J Safety Res. 2022;83:105-118. doi:10.1016/j.jsr.2022.08.008. Copy Citation …

Adverse drug events in general practice patients in Australia. | PSNet

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March 04, 2020 - Study Adverse drug events in general practice patients in Australia. Citation Text: Miller GC, Britth HC, Valenti L. Adverse drug events in general practice patients in Australia. Med J Aust. 2006;184(7):321-4. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3…

Therapeutic errors involving adults in the community setting: nature, causes and outcomes. | PSNet

psnet.ahrq.gov/issue/therapeutic-errors-involving-adults-community-setting-nature-causes-and-outcomes

May 24, 2009 - Study Therapeutic errors involving adults in the community setting: nature, causes and outcomes. Citation Text: Taylor D, Robinson J, MacLeod D, et al. Therapeutic errors involving adults in the community setting: nature, causes and outcomes. Aust N Z J Public Health. 2009;33(4):388-94…

The evolution of procedural competency in internal medicine training. | PSNet

psnet.ahrq.gov/issue/evolution-procedural-competency-internal-medicine-training

December 15, 2021 - Commentary The evolution of procedural competency in internal medicine training. Citation Text: Sacks CA, Alba GA, Miloslavsky EM. The Evolution of Procedural Competency in Internal Medicine Training. JAMA Intern Med. 2017;177(12):1713-1714. doi:10.1001/jamainternmed.2017.5014. Copy Ci…

Active-shooter response at a health care facility. | PSNet

psnet.ahrq.gov/issue/active-shooter-response-health-care-facility

January 18, 2012 - Commentary Active-shooter response at a health care facility. Citation Text: Inaba K, Eastman AL, Jacobs LM, et al. Active-Shooter Response at a Health Care Facility. N Engl J Med. 2018;379(6):583-586. doi:10.1056/NEJMms1800582. Copy Citation Format: DOI Google Scholar PubM…

Acceptance of recommendations by inpatient pharmacy case managers: unintended consequences of hospitalist and specialist care. | PSNet

psnet.ahrq.gov/issue/acceptance-recommendations-inpatient-pharmacy-case-managers-unintended-consequences

November 16, 2022 - Study Acceptance of recommendations by inpatient pharmacy case managers: unintended consequences of hospitalist and specialist care. Citation Text: Anderegg S, Demik DE, Carter BL, et al. Acceptance of recommendations by inpatient pharmacy case managers: unintended consequences of hosp…

Implementation of a specialized pharmacy team to monitor high-risk medications during discharge. | PSNet

psnet.ahrq.gov/issue/implementation-specialized-pharmacy-team-monitor-high-risk-medications-during-discharge

September 23, 2020 - Commentary Implementation of a specialized pharmacy team to monitor high-risk medications during discharge. Citation Text: Martin ES, Overstreet RL, Jackson-Khalil LR, et al. Implementation of a specialized pharmacy team to monitor high-risk medications during discharge. Am J Health S…

FDA Safety Communication: use caution with implanted pumps for intrathecal administration of medicines for pain management. | PSNet

psnet.ahrq.gov/issue/fda-safety-communication-use-caution-implanted-pumps-intrathecal-administration-medicines

June 20, 2018 - Press Release/Announcement FDA Safety Communication: use caution with implanted pumps for intrathecal administration of medicines for pain management. Citation Text: FDA Safety Communication: use caution with implanted pumps for intrathecal administration of medicines for pain management…

Impact of an antiretroviral stewardship strategy on medication error rates. | PSNet

psnet.ahrq.gov/issue/impact-antiretroviral-stewardship-strategy-medication-error-rates

August 04, 2021 - Study Impact of an antiretroviral stewardship strategy on medication error rates. Citation Text: Shea KM, Hobbs AL, Shumake JD, et al. Impact of an antiretroviral stewardship strategy on medication error rates. Am J Health Syst Pharm. 2018;75(12):876-885. doi:10.2146/ajhp170420. Copy C…

Beyond service quality: the mediating role of patient safety perceptions in the patient experience–satisfaction relationship. | PSNet

psnet.ahrq.gov/issue/beyond-service-quality-mediating-role-patient-safety-perceptions-patient-experience

January 14, 2011 - Study Beyond service quality: the mediating role of patient safety perceptions in the patient experience–satisfaction relationship. Citation Text: Rathert C, May DR, Williams E. Beyond service quality: the mediating role of patient safety perceptions in the patient experience-satisfac…

An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions. | PSNet

psnet.ahrq.gov/issue/evidence-based-toolkit-development-effective-and-sustainable-root-cause-analysis-system

June 01, 2019 - Study An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions. Citation Text: Hettinger Z, Fairbanks RJ, Hegde S, et al. An evidence-based toolkit for the development of effective and sustainable root cause analysis syste…

Nurses' clinical reasoning practices that support safe medication administration: an integrative review of the literature. | PSNet

psnet.ahrq.gov/issue/nurses-clinical-reasoning-practices-support-safe-medication-administration-integrative-review

October 19, 2022 - Review Nurses' clinical reasoning practices that support safe medication administration: an integrative review of the literature. Citation Text: Rohde E, Domm E. Nurses' clinical reasoning practices that support safe medication administration: An integrative review of the literature. J C…

Validation of a mobile app for reducing errors of administration of medications in an emergency. | PSNet

psnet.ahrq.gov/issue/validation-mobile-app-reducing-errors-administration-medications-emergency

September 23, 2020 - Study Validation of a mobile app for reducing errors of administration of medications in an emergency. Citation Text: Baumann D, Dibbern N, Sehner S, et al. Validation of a mobile app for reducing errors of administration of medications in an emergency. J Clin Monit Comput. . 2019;33(3):…

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