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psnet.ahrq.gov/issue/timing-surgical-antimicrobial-prophylaxis
June 24, 2009 - Study
The timing of surgical antimicrobial prophylaxis.
Citation Text:
Weber WP, Marti WR, Zwahlen M, et al. The Timing of Surgical Antimicrobial Prophylaxis. Ann Surg. 2008;247(6). doi:10.1097/sla.0b013e31816c3fec.
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psnet.ahrq.gov/issue/educating-21st-century-health-care-system-interdependent-framework-basic-clinical-and-systems
August 28, 2024 - Commentary
Educating for the 21st-century health care system: an interdependent framework of basic, clinical, and systems sciences.
Citation Text:
Gonzalo JD, Haidet P, Papp KK, et al. Educating for the 21st-Century Health Care System: An Interdependent Framework of Basic, Clinical, and …
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psnet.ahrq.gov/issue/national-action-plan-adverse-drug-event-prevention
October 16, 2013 - Book/Report
National Action Plan for Adverse Drug Event Prevention.
Citation Text:
National Action Plan for Adverse Drug Event Prevention. Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health and Human Services; September 2014.
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psnet.ahrq.gov/issue/preventing-and-mitigating-radiology-system-failures-guide-disaster-planning
November 23, 2016 - Commentary
Preventing and mitigating radiology system failures: a guide to disaster planning.
Citation Text:
Gibney BT, Roberts JM, D'Ortenzio RM, et al. Preventing and mitigating radiology system failures: a guide to disaster planning. RadioGraphics. 2021;41(7):2111-2126. doi:10.1148/rg…
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psnet.ahrq.gov/issue/provider-and-pharmacist-responses-warfarin-drug-drug-interaction-alerts-study-healthcare
July 29, 2020 - Study
Provider and pharmacist responses to warfarin drug–drug interaction alerts: a study of healthcare downstream of CPOE alerts.
Citation Text:
Miller AM, Boro MS, Korman NE, et al. Provider and pharmacist responses to warfarin drug-drug interaction alerts: a study of healthcare downst…
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psnet.ahrq.gov/issue/was-close-call-endorsing-broad-definition-near-misses-health-care
August 31, 2016 - Commentary
"That was a close call": endorsing a broad definition of near misses in health care.
Citation Text:
Marks CM, Kasda E, Paine LA, et al. "That was a close call": endorsing a broad definition of near misses in health care. Jt Comm J Qual Patient Saf. 2013;39(10):475-479.
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psnet.ahrq.gov/issue/charter-professionalism-health-care-organizations
May 25, 2016 - Commentary
The Charter on Professionalism for Health Care Organizations.
Citation Text:
Egener BE, Mason DJ, McDonald WJ, et al. The Charter on Professionalism for Health Care Organizations. Acad Med. 2017;92(8):1091-1099. doi:10.1097/ACM.0000000000001561.
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psnet.ahrq.gov/issue/communication-and-information-deficits-patients-discharged-rehabilitation-facilities
January 11, 2017 - Study
Communication and information deficits in patients discharged to rehabilitation facilities: an evaluation of five acute care hospitals.
Citation Text:
Gandara E, Moniz T, Ungar J, et al. Communication and information deficits in patients discharged to rehabilitation facilities: An …
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psnet.ahrq.gov/issue/potential-medication-errors-associated-computer-prescriber-order-entry
May 05, 2014 - Study
Potential medication errors associated with computer prescriber order entry.
Citation Text:
Villamañán E, Larrubia Y, Ruano M, et al. Potential medication errors associated with computer prescriber order entry. Int J Clin Pharm. 2013;35(4):577-83. doi:10.1007/s11096-013-9771-2. …
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psnet.ahrq.gov/issue/preventing-blood-transfusion-failures-fmea-effective-assessment-method
August 25, 2021 - Study
Preventing blood transfusion failures: FMEA, an effective assessment method.
Citation Text:
Najafpour Z, Hasoumi M, Behzadi F, et al. Preventing blood transfusion failures: FMEA, an effective assessment method. BMC Health Serv Res. 2017;17(1):453. doi:10.1186/s12913-017-2380-3.
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psnet.ahrq.gov/issue/incorporating-medication-indications-prescribing-process
May 01, 2019 - Commentary
Emerging Classic
Incorporating medication indications into the prescribing process.
Citation Text:
Kron K, Myers S, Volk LA, et al. Incorporating medication indications into the prescribing process. Am J Health-syst Pharm. 2018;75(11):774-783. doi:10.…
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psnet.ahrq.gov/issue/prospective-hazard-and-improvement-analytic-approach-predicting-effectiveness-medication
December 04, 2013 - Study
A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions.
Citation Text:
Karnon J, McIntosh A, Dean JE, et al. A prospective hazard and improvement analytic approach to predicting the effectiveness of medication erro…
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psnet.ahrq.gov/issue/crisis-preparedness-systems-based-framework-avoiding-harm-surgery
September 14, 2022 - Study
Crisis preparedness: a systems-based framework for avoiding harm in surgery.
Citation Text:
Gogalniceanu P, Karydis N, Costan V-V, et al. Crisis preparedness: a systems-based framework for avoiding harm in surgery. J Am Coll Surg. 2022;235(4):612-623. doi:10.1097/xcs.00000000000003…
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psnet.ahrq.gov/issue/epidural-pump-programming-error-leading-inadvertent-10-fold-dosing-error-during-epidural
May 13, 2009 - Commentary
Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.
Citation Text:
Thyen AB, McAllister RK, Councilman LM. Epidural Pump Programming Error Leading to Inadvertent 10-Fold Dosing Error During Epidural La…
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psnet.ahrq.gov/issue/barcode-medication-administration-software-technology-use-emergency-department-and-medication
November 04, 2015 - Study
Barcode medication administration software technology use in the emergency department and medication error rates.
Citation Text:
Gauthier-Wetzel HE. Barcode medication administration software technology use in the emergency department and medication error rates. Comput Inform Nurs.…
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psnet.ahrq.gov/issue/patient-safety-systems-primary-health-care-diabetes-story-missed-opportunities
March 28, 2011 - Review
Patient safety systems in the primary health care of diabetes—a story of missed opportunities?
Citation Text:
Taub N, Baker R, Khunti K, et al. Patient safety systems in the primary health care of diabetes—a story of missed opportunities? Diabet Med. 2010;27(11):1322-6.
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psnet.ahrq.gov/issue/safe-chemotherapy-administration-using-failure-mode-and-effects-analysis-computerized
October 19, 2022 - Commentary
Safe chemotherapy administration: using failure mode and effects analysis in computerized prescriber order entry.
Citation Text:
Kozakiewicz JM, Benis LJ, Fisher SM, et al. Safe chemotherapy administration: Using failure mode and effects analysis in computerized prescriber o…
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psnet.ahrq.gov/issue/identifying-high-alert-medications-university-hospital-applying-data-medication-error
August 03, 2017 - Study
Identifying high-alert medications in a university hospital by applying data from the medication error reporting system.
Citation Text:
Tyynismaa L, Honkala A, Airaksinen M, et al. Identifying High-alert Medications in a University Hospital by Applying Data From the Medication Erro…
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psnet.ahrq.gov/issue/power-written-word-reflection-reduces-errors-omission
April 24, 2018 - Study
The power of written word: reflection reduces errors of omission.
Citation Text:
Rao A, Heidemann LA, Hartley S, et al. The power of written word: reflection reduces errors of omission. Clin Teach. 2024;21(1):e13630. doi:10.1111/tct.13630.
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psnet.ahrq.gov/issue/clinical-review-hospital-future-building-intelligent-environments-facilitate-safe-and
March 16, 2022 - Review
Clinical review: the hospital of the future—building intelligent environments to facilitate safe and effective acute care delivery.
Citation Text:
Pickering BW, Litell JM, Herasevich V, et al. Clinical review: the hospital of the future - building intelligent environments to faci…