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  1. Racial and ethnic harm in patient care is a patient safety issue. | PSNet

    psnet.ahrq.gov/issue/racial-and-ethnic-harm-patient-care-patient-safety-issue
    October 21, 2020 - Commentary Racial and ethnic harm in patient care is a patient safety issue. Citation Text: Rosario N, Kiles TM, M. Jewell T'B, et al. Racial and ethnic harm in patient care is a patient safety issue. Res Social Adm Pharm. 2024;20(7):670-677. doi:10.1016/j.sapharm.2024.04.012. Copy Cit…

  2. Making residents part of the safety culture: improving error reporting and reducing harms. | PSNet

    psnet.ahrq.gov/issue/making-residents-part-safety-culture-improving-error-reporting-and-reducing-harms
    April 24, 2018 - Commentary Making residents part of the safety culture: improving error reporting and reducing harms. Citation Text: Fox MD, Bump GM, Butler GA, et al. Making Residents Part of the Safety Culture: Improving Error Reporting and Reducing Harms. J Patient Saf. 2021;17(5):e373-e378. doi:10.1…

  3. High-alert medication administration and intravenous smart pumps: a descriptive analysis of clinical practice. | PSNet

    psnet.ahrq.gov/issue/high-alert-medication-administration-and-intravenous-smart-pumps-descriptive-analysis
    December 12, 2018 - Study High-alert medication administration and intravenous smart pumps: a descriptive analysis of clinical practice. Citation Text: Marwitz KK, Giuliano KK, Su W-T, et al. High-alert medication administration and intravenous smart pumps: A descriptive analysis of clinical practice. Res S…

  4. Development and early experience from an intervention to facilitate teamwork between general practices and allied health providers: the Team-link study. | PSNet

    psnet.ahrq.gov/issue/development-and-early-experience-intervention-facilitate-teamwork-between-general-practices
    June 29, 2011 - Study Development and early experience from an intervention to facilitate teamwork between general practices and allied health providers: the Team-link study. Citation Text: Harris MF, Chan BC, Daniel C, et al. Development and early experience from an intervention to facilitate teamwor…

  5. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. | PSNet

    psnet.ahrq.gov/issue/diagnostic-blood-loss-phlebotomy-and-hospital-acquired-anemia-during-acute-myocardial
    March 14, 2022 - Study Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Citation Text: Salisbury AC, Reid KJ, Alexander KP, et al. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med…

  6. Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review. | PSNet

    psnet.ahrq.gov/issue/problems-health-information-technology-and-their-effects-care-delivery-and-patient-outcomes
    February 14, 2024 - Review Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review. Citation Text: Kim MO, Coiera E, Magrabi F. Problems with health information technology and their effects on care delivery and patient outcomes: a systematic r…

  7. SAFER Care: improving caregiver comprehension of discharge instructions. | PSNet

    psnet.ahrq.gov/issue/safer-care-improving-caregiver-comprehension-discharge-instructions
    October 26, 2022 - Study SAFER Care: improving caregiver comprehension of discharge instructions. Citation Text: Uong A, Philips K, Hametz P, et al. SAFER care: improving caregiver comprehension of discharge instructions. Pediatrics. 2021;147(4):e20200031. doi:10.1542/peds.2020-0031. Copy Citation Fo…

  8. Closing the gap and raising the bar: assessing board competency in quality and safety. | PSNet

    psnet.ahrq.gov/issue/closing-gap-and-raising-bar-assessing-board-competency-quality-and-safety
    July 20, 2022 - Study Closing the gap and raising the bar: assessing board competency in quality and safety. Citation Text: McGaffigan PA, Ullem BD, Gandhi TK. Closing the Gap and Raising the Bar: Assessing Board Competency in Quality and Safety. Jt Comm J Qual Patient Saf. 2017;43(6):267-274. doi:10.10…

  9. Defining the incidence of cardiorespiratory instability in patients in step-down units using an electronic integrated monitoring system. | PSNet

    psnet.ahrq.gov/issue/defining-incidence-cardiorespiratory-instability-patients-step-down-units-using-electronic
    September 04, 2013 - Study Defining the incidence of cardiorespiratory instability in patients in step-down units using an electronic integrated monitoring system. Citation Text: Hravnak M, Edwards L, Clontz A, et al. Defining the incidence of cardiorespiratory instability in patients in step-down units us…

  10. Medication error reporting in rural critical access hospitals in the North Dakota Telepharmacy Project. | PSNet

    psnet.ahrq.gov/issue/medication-error-reporting-rural-critical-access-hospitals-north-dakota-telepharmacy-project
    October 17, 2012 - Study Medication error reporting in rural critical access hospitals in the North Dakota Telepharmacy Project. Citation Text: Scott DM, Friesner DL, Rathke AM, et al. Medication error reporting in rural critical access hospitals in the North Dakota Telepharmacy Project. Am J Health Syst …

  11. Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a literature review. | PSNet

    psnet.ahrq.gov/issue/use-and-implementation-standard-operating-procedures-and-checklists-prehospital-emergency
    August 28, 2024 - Review Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a literature review. Citation Text: Chen C, Kan T, Li S, et al. Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a lit…

  12. Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit. | PSNet

    psnet.ahrq.gov/issue/direct-observation-approach-detecting-medication-errors-and-adverse-drug-events-pediatric
    June 28, 2010 - Study Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit. Citation Text: Buckley MS, Erstad BL, Kopp BJ, et al. Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensi…

  13. Advances in Patient Safety and Medical Liability. | PSNet

    psnet.ahrq.gov/issue/advances-patient-safety-and-medical-liability
    May 01, 2017 - Book/Report Classic Advances in Patient Safety and Medical Liability. Citation Text: Advances in Patient Safety and Medical Liability. Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2017. AHRQ Publication No…

  14. Evidence-based guidelines for fatigue risk management in emergency medical services. | PSNet

    psnet.ahrq.gov/issue/evidence-based-guidelines-fatigue-risk-management-emergency-medical-services
    August 03, 2017 - Review Evidence-based guidelines for fatigue risk management in emergency medical services. Citation Text: Patterson D, Higgins S, Van Dongen HPA, et al. Evidence-Based Guidelines for Fatigue Risk Management in Emergency Medical Services. Prehosp Emerg Care. 2018;22(sup1):89-101. doi:10.…

  15. Consumer-directed technologies to improve medication management and safety. | PSNet

    psnet.ahrq.gov/issue/consumer-directed-technologies-improve-medication-management-and-safety
    December 29, 2014 - Commentary Consumer-directed technologies to improve medication management and safety. Citation Text: Andrade AQ, Roughead EE. Consumer-directed technologies to improve medication management and safety. Med J Aust. 2019;210(suppl 6):S24-S27. doi:10.5694/mja2.50029. Copy Citation Fo…

  16. Promoting patient safety through prospective risk identification: example from peri-operative care. | PSNet

    psnet.ahrq.gov/issue/promoting-patient-safety-through-prospective-risk-identification-example-peri-operative-care
    September 23, 2020 - Study Promoting patient safety through prospective risk identification: example from peri-operative care. Citation Text: Smith AF, Boult M, Woods I, et al. Promoting patient safety through prospective risk identification: example from peri-operative care. Qual Saf Health Care. 2010;19(…

  17. The flaw of medicine: addressing racial and gender disparities in critical care. | PSNet

    psnet.ahrq.gov/issue/flaw-medicine-addressing-racial-and-gender-disparities-critical-care
    June 16, 2010 - Commentary The flaw of medicine: addressing racial and gender disparities in critical care. Citation Text: Hilton EJ, Goff KL, Sreedharan R, et al. The flaw of medicine: addressing racial and gender disparities in critical care. Anesthesiol Clin. 2020;38(2):357-368. doi:10.1016/j.anclin.…

  18. Revisiting duty-hour limits — IOM recommendations for patient safety and resident education. | PSNet

    psnet.ahrq.gov/issue/revisiting-duty-hour-limits-iom-recommendations-patient-safety-and-resident-education
    February 17, 2011 - Commentary Revisiting duty-hour limits — IOM recommendations for patient safety and resident education. Citation Text: Iglehart JK. Revisiting duty-hour limits--IOM recommendations for patient safety and resident education. N Engl J Med. 2008;359(25):2633-5. doi:10.1056/NEJMp0808736. …

  19. Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence. | PSNet

    psnet.ahrq.gov/issue/linking-joint-commission-inpatient-core-measures-and-national-patient-safety-goals-evidence
    October 19, 2022 - Commentary Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence. Citation Text: Masica AL, Richter KM, Convery P, et al. Linking joint commission inpatient core measures and national patient safety goals with evidence. Proc (Bayl Univ Med Cen…

  20. Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety. | PSNet

    psnet.ahrq.gov/issue/optimizing-graduate-medical-trainee-resident-hours-and-work-schedules-improve-patient-safety
    July 05, 2008 - Book/Report Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety. Citation Text: Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety. Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Gra…
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