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  1. New solutions to reduce wrong route medication errors. | PSNet

    psnet.ahrq.gov/issue/new-solutions-reduce-wrong-route-medication-errors
    March 20, 2019 - Review New solutions to reduce wrong route medication errors. Citation Text: Litman RS, Smith VI, Mainland P. New solutions to reduce wrong route medication errors. Paediatr Anaesth. 2018;28(1):8-12. doi:10.1111/pan.13279. Copy Citation Format: DOI Google Scholar PubMed Bib…

  2. Nil per os orders for imaging: a teachable moment. | PSNet

    psnet.ahrq.gov/issue/nil-os-orders-imaging-teachable-moment
    November 13, 2024 - Commentary Nil per os orders for imaging: a teachable moment. Citation Text: Wickerham AL, Schultz EJ, Lewine EB. Nil per Os Orders for Imaging: A Teachable Moment. JAMA Intern Med. 2017;177(11):1670-1671. doi:10.1001/jamainternmed.2017.3943. Copy Citation Format: DOI Googl…

  3. An approach to assessing patient safety in hospitals in low-income countries. | PSNet

    psnet.ahrq.gov/issue/approach-assessing-patient-safety-hospitals-low-income-countries
    July 22, 2020 - Study An approach to assessing patient safety in hospitals in low-income countries. Citation Text: Lindfield R, Knight A, Bwonya D. An approach to assessing patient safety in hospitals in low-income countries. PLoS One. 2015;10(3):e0121628. doi:10.1371/journal.pone.0121628. Copy Citati…

  4. Interns overestimate the effectiveness of their hand-off communication. | PSNet

    psnet.ahrq.gov/issue/interns-overestimate-effectiveness-their-hand-communication
    March 02, 2011 - Study Interns overestimate the effectiveness of their hand-off communication. Citation Text: Chang VY, Arora V, Lev-Ari S, et al. Interns overestimate the effectiveness of their hand-off communication. Pediatrics. 2010;125(3):491-496. doi:10.1542/peds.2009-0351. Copy Citation For…

  5. Leveraging consistent communication tools and organizational values to promote accountability among health care providers. | PSNet

    psnet.ahrq.gov/issue/leveraging-consistent-communication-tools-and-organizational-values-promote-accountability
    January 18, 2023 - Commentary Leveraging consistent communication tools and organizational values to promote accountability among health care providers. Citation Text: Baldwin CA, Krumm AM. Leveraging consistent communication tools and organizational values to promote accountability among health care provi…

  6. Health Care Quality and Disparities: Lessons from the First National Reports. | PSNet

    psnet.ahrq.gov/issue/health-care-quality-and-disparities-lessons-first-national-reports
    April 03, 2005 - Special or Theme Issue Health Care Quality and Disparities: Lessons from the First National Reports. Citation Text: Health Care Quality and Disparities: Lessons from the First National Reports. Kelley E, Moy E, Dayton E, et al. Med Care. 2005:43(3):I1-I88. Copy Citation …

  7. Practical application of high-reliability principles in healthcare to optimize quality and safety outcomes. | PSNet

    psnet.ahrq.gov/issue/practical-application-high-reliability-principles-healthcare-optimize-quality-and-safety
    August 14, 2024 - Commentary Practical application of high-reliability principles in healthcare to optimize quality and safety outcomes. Citation Text: Oster CA, Deakins S. Practical Application of High-Reliability Principles in Healthcare to Optimize Quality and Safety Outcomes. J Nurs Admin. 2017;48(1):…

  8. Overuse of medical imaging and its radiation exposure: who’s minding our children? | PSNet

    psnet.ahrq.gov/issue/overuse-medical-imaging-and-its-radiation-exposure-whos-minding-our-children
    August 04, 2021 - Commentary Overuse of medical imaging and its radiation exposure: who’s minding our children? Citation Text: Schroeder AR, Duncan JR. Overuse of Medical Imaging and Its Radiation Exposure: Who's Minding Our Children? JAMA Pediatr. 2016;170(11):1037-1038. doi:10.1001/jamapediatrics.2016.2…

  9. Sidelining safety — the FDA's inadequate response to the IOM. | PSNet

    psnet.ahrq.gov/issue/sidelining-safety-fdas-inadequate-response-iom
    November 13, 2009 - Commentary Sidelining safety — the FDA's inadequate response to the IOM. Citation Text: Smith SW. Sidelining safety--the FDA's inadequate response to the IOM. N Engl J Med. 2007;357(10):960-3. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML…

  10. Automated dispensing cabinets and their impact on the rate of omitted and delayed doses: a systematic review. | PSNet

    psnet.ahrq.gov/issue/automated-dispensing-cabinets-and-their-impact-rate-omitted-and-delayed-doses-systematic
    October 12, 2022 - Review Automated dispensing cabinets and their impact on the rate of omitted and delayed doses: a systematic review. Citation Text: Jeffrey E, Dalby M, Walsh Á, et al. Automated dispensing cabinets and their impact on the rate of omitted and delayed doses: a systematic review. Explor Res…

  11. Diagnostic delays and errors in head and neck cancer patients: opportunities for improvement. | PSNet

    psnet.ahrq.gov/issue/diagnostic-delays-and-errors-head-and-neck-cancer-patients-opportunities-improvement
    March 14, 2022 - Study Diagnostic delays and errors in head and neck cancer patients: opportunities for improvement. Citation Text: Franco J, Elghouche AN, Harris MS, et al. Diagnostic Delays and Errors in Head and Neck Cancer Patients: Opportunities for Improvement. Am J Med Qual. 2017;32(3):330-335. do…

  12. Walking a tightrope: balancing the risk of diagnostic error in inpatient pediatrics. | PSNet

    psnet.ahrq.gov/issue/walking-tightrope-balancing-risk-diagnostic-error-inpatient-pediatrics
    May 29, 2019 - Commentary Walking a tightrope: balancing the risk of diagnostic error in inpatient pediatrics. Citation Text: Berkwitt A, Osborn R, Grossman M. Walking a Tightrope: Balancing the Risk of Diagnostic Error in Inpatient Pediatrics. Hosp Pediatr. 2016;6(9):566-8. doi:10.1542/hpeds.2016-0043…

  13. Nurse health, work environment, presenteeism and patient safety. | PSNet

    psnet.ahrq.gov/issue/nurse-health-work-environment-presenteeism-and-patient-safety
    December 14, 2016 - Study Nurse health, work environment, presenteeism and patient safety. Citation Text: Rainbow JG, Drake DA, Steege LM. Nurse health, work environment, presenteeism and patient safety. West J Nurs Res. 2020;42(5):332-339. doi:10.1177/0193945919863409. Copy Citation Format: D…

  14. How Discrimination in Health Care Affects Older Americans, and What Health Systems and Providers Can Do. | PSNet

    psnet.ahrq.gov/issue/how-discrimination-health-care-affects-older-americans-and-what-health-systems-and-providers
    February 28, 2024 - Book/Report How Discrimination in Health Care Affects Older Americans, and What Health Systems and Providers Can Do. Citation Text: How Discrimination in Health Care Affects Older Americans, and What Health Systems and Providers Can Do. Doty MM, Horstman C, Shah A et al. Issue Brief. New…

  15. Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. | PSNet

    psnet.ahrq.gov/issue/use-anatomic-marking-form-alternative-universal-protocol-preventing-wrong-site-wrong
    March 02, 2011 - Commentary Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. Citation Text: Knight N, Aucar J. Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong…

  16. The problem with medication reconciliation. | PSNet

    psnet.ahrq.gov/issue/problem-medication-reconciliation
    May 08, 2017 - Commentary The problem with medication reconciliation. Citation Text: Pevnick JM, Shane R, Schnipper JL. The problem with medication reconciliation. BMJ Qual Saf. 2016;25(9):726-730. doi:10.1136/bmjqs-2015-004734. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNo…

  17. Coaching the debriefer: peer coaching to improve debriefing quality in simulation programs. | PSNet

    psnet.ahrq.gov/issue/coaching-debriefer-peer-coaching-improve-debriefing-quality-simulation-programs
    July 31, 2019 - Commentary Coaching the debriefer: peer coaching to improve debriefing quality in simulation programs. Citation Text: Cheng A, Grant V, Huffman J, et al. Coaching the Debriefer: Peer Coaching to Improve Debriefing Quality in Simulation Programs. Simul Healthc. 2017;12(5):319-325. doi:10.…

  18. Impact of high-reliability education on adverse event reporting by registered nurses. | PSNet

    psnet.ahrq.gov/issue/impact-high-reliability-education-adverse-event-reporting-registered-nurses
    January 07, 2011 - Study Impact of high-reliability education on adverse event reporting by registered nurses. Citation Text: McFarland DM, Doucette JN. Impact of High-Reliability Education on Adverse Event Reporting by Registered Nurses. J Nurs Care Qual. 2018;33(3):285-290. doi:10.1097/NCQ.00000000000002…

  19. Diseases of medical progress. | PSNet

    psnet.ahrq.gov/issue/diseases-medical-progress
    June 27, 2018 - Review Classic Diseases of medical progress. Citation Text: MOSER RH. Diseases of medical progress. N Engl J Med. 1956;255(13):606-14. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  20. Ensuring access to medications in the US during the COVID-19 pandemic. | PSNet

    psnet.ahrq.gov/issue/ensuring-access-medications-us-during-covid-19-pandemic
    May 08, 2017 - March 30, 2022 Prescription opioid analgesics commonly unused after surgery: a systematic
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