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  1. Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-miss surgical events. | PSNet

    psnet.ahrq.gov/issue/duke-surgery-patient-safety-open-source-application-anonymous-reporting-adverse-and-near-miss
    February 15, 2011 - Commentary Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-miss surgical events. Citation Text: Pietrobon R, Lima R, Shah A, et al. Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-mi…

  2. Reportable incidents. | PSNet

    psnet.ahrq.gov/issue/reportable-incidents
    November 02, 2016 - Newspaper/Magazine Article Reportable incidents. Citation Text: Barishansky RM, Glick DE. Reportable incidents. Establishing policies and procedures for when calls go wrong. EMS magazine. 2009;38(3):43-7. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML End…

  3. Tubing misconnections: normalization of deviance. | PSNet

    psnet.ahrq.gov/issue/tubing-misconnections-normalization-deviance
    December 16, 2015 - Review Tubing misconnections: normalization of deviance. Citation Text: Simmons D, Symes L, Guenter P, et al. Tubing misconnections: normalization of deviance. Nutr Clin Pract. 2011;26(3):286-293. doi:10.1177/0884533611406134. Copy Citation Format: DOI Google Scholar PubM…

  4. Infusing fun into quality and safety initiatives. | PSNet

    psnet.ahrq.gov/issue/infusing-fun-quality-and-safety-initiatives
    October 19, 2022 - Commentary Infusing fun into quality and safety initiatives. Citation Text: Foulk KC, Tocydlowski P, Snow TM, et al. Infusing fun into quality and safety initiatives. Nursing (Brux). 2012;42(11):14-16. doi:10.1097/01.NURSE.0000421386.36112.a9. Copy Citation Format: DOI Goo…

  5. A review of educational philosophies as applied to radiation safety training at medical institutions. | PSNet

    psnet.ahrq.gov/issue/review-educational-philosophies-applied-radiation-safety-training-medical-institutions
    May 31, 2017 - Commentary A review of educational philosophies as applied to radiation safety training at medical institutions. Citation Text: Dauer LT, St Germain J. A review of educational philosophies as applied to radiation safety training at medical institutions. Health Phys. 2006;90(5 Suppl):S6…

  6. Applying the Toyota Production System: using a patient safety alert system to reduce error. | PSNet

    psnet.ahrq.gov/issue/applying-toyota-production-system-using-patient-safety-alert-system-reduce-error
    June 21, 2015 - Commentary Applying the Toyota Production System: using a patient safety alert system to reduce error. Citation Text: Furman C, Caplan RA. Applying the Toyota Production System: using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf. 2007;33(7):376-386. Copy …

  7. Simulation for operational readiness in a new freestanding emergency department: strategy and tactics. | PSNet

    psnet.ahrq.gov/issue/simulation-operational-readiness-new-freestanding-emergency-department-strategy-and-tactics
    August 20, 2018 - Study Simulation for operational readiness in a new freestanding emergency department: strategy and tactics. Citation Text: Kerner RL, Gallo K, Cassara M, et al. Simulation for Operational Readiness in a New Freestanding Emergency Department. Simul Healthc. 2016;11(5). doi:10.1097/sih.00…

  8. Learning from malpractice claims about negligent, adverse events in primary care in the United States. | PSNet

    psnet.ahrq.gov/issue/learning-malpractice-claims-about-negligent-adverse-events-primary-care-united-states
    April 07, 2011 - Study Learning from malpractice claims about negligent, adverse events in primary care in the United States. Citation Text: Phillips RL, Bartholomew LA, Dovey S, et al. Learning from malpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Healt…

  9. Management of the difficult airway: a closed claims analysis. | PSNet

    psnet.ahrq.gov/issue/management-difficult-airway-closed-claims-analysis
    July 13, 2010 - Study Management of the difficult airway: a closed claims analysis. Citation Text: Peterson GN, Domino KB, Caplan RA, et al. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005;103(1):33-39. Copy Citation Format: Google Scholar PubMed BibTeX…

  10. 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…

  11. Quality and Safety in Nursing: a Competency Approach to Improving Outcomes, Second Edition. | PSNet

    psnet.ahrq.gov/issue/quality-and-safety-nursing-competency-approach-improving-outcomes-second-edition
    May 13, 2009 - Book/Report Quality and Safety in Nursing: a Competency Approach to Improving Outcomes, Second Edition. Citation Text: Quality and Safety in Nursing: a Competency Approach to Improving Outcomes, Second Edition. Sherwood G, Barnsteiner J, eds. Hoboken, NJ: Wiley-Blackwell; 2017. ISBN: 978…

  12. The effect of collaboration on obstetric patient safety in three academic facilities. | PSNet

    psnet.ahrq.gov/issue/effect-collaboration-obstetric-patient-safety-three-academic-facilities
    October 19, 2022 - Commentary The effect of collaboration on obstetric patient safety in three academic facilities. Citation Text: Raab CA, Will SEB, Richards SL, et al. The Effect of Collaboration on Obstetric Patient Safety in Three Academic Facilities. Journal of Obstetric, Gynecologic & Neonatal Nursi…

  13. Usability study of two common defibrillators reveals hazards. | PSNet

    psnet.ahrq.gov/issue/usability-study-two-common-defibrillators-reveals-hazards
    June 16, 2009 - Study Usability study of two common defibrillators reveals hazards. Citation Text: Fairbanks RJ, Caplan SH, Bishop PA, et al. Usability Study of Two Common Defibrillators Reveals Hazards. Ann Emerg Med. 2007;50(4):424-432. doi:10.1016/j.annemergmed.2007.03.029. Copy Citation Form…

  14. Insights into the climate of safety towards the prevention of falls among hospital staff. | PSNet

    psnet.ahrq.gov/issue/insights-climate-safety-towards-prevention-falls-among-hospital-staff
    February 14, 2017 - Study Insights into the climate of safety towards the prevention of falls among hospital staff. Citation Text: Black AA, Brauer SG, Bell RAR, et al. Insights into the climate of safety towards the prevention of falls among hospital staff. J Clin Nurs. 2011;20(19-20):2924-30. doi:10.111…

  15. Clinical questions raised by clinicians at the point of care: a systematic review. | PSNet

    psnet.ahrq.gov/issue/clinical-questions-raised-clinicians-point-care-systematic-review
    May 04, 2022 - Review Clinical questions raised by clinicians at the point of care: a systematic review. Citation Text: Del Fiol G, Workman E, Gorman PN. Clinical questions raised by clinicians at the point of care: a systematic review. JAMA Intern Med. 2014;174(5):710-8. doi:10.1001/jamainternmed.2014…

  16. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.60_slideshow.ppt
    May 01, 2004 - Intensive Insulin Therapy Automated order sets and preprinted order sheets Effective in reducing medication … errors related to chemotherapy dosing Effective in ensuring appropriate therapy for myocardial infarction

  17. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? | PSNet

    psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
    June 24, 2020 - April 29, 2018 NICU medication errors: identifying a risk profile for medication errors

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38487/psn-pdf
    March 18, 2009 - Greater nursing experience also was correlated with lower rates of medication errors.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42309/psn-pdf
    May 18, 2016 - psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-and-quality-award https://psnet.ahrq.gov/issue/medication-errors-involving-oral-chemotherapy

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43062/psn-pdf
    September 04, 2016 - evidence linking safety culture and patient outcomes, including satisfaction, falls, readmission rates, medication … errors, and mortality.
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