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psnet.ahrq.gov/issue/doctors-new-dilemma
November 13, 2024 - Commentary
The doctor's new dilemma.
Citation Text:
Koven S. The Doctor's New Dilemma. N Engl J Med. 2016;374(7):608-9. doi:10.1056/NEJMp1513708.
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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.
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psnet.ahrq.gov/issue/alarm-fatigue-use-evidence-based-alarm-management-strategy
July 24, 2024 - Commentary
Alarm fatigue: use of an evidence-based alarm management strategy.
Citation Text:
Turmell JW, Coke L, Catinella R, et al. Alarm Fatigue. J Nurs Care Qual. 2016;32(1):47-54. doi:10.1097/ncq.0000000000000223.
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psnet.ahrq.gov/issue/method-addressing-proprietary-name-similarity-us-prescription-drugs
June 10, 2020 - Commentary
A method of addressing proprietary name similarity for US prescription drugs.
Citation Text:
Stockbridge MD, Taylor K. A Method of Addressing Proprietary Name Similarity for US Prescription Drugs. Ther Innov Regul Sci. 2015;49(4). doi:10.1177/2168479015570331.
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psnet.ahrq.gov/issue/educational-and-audit-tool-reduce-prescribing-error-intensive-care
August 04, 2021 - Study
An educational and audit tool to reduce prescribing error in intensive care.
Citation Text:
Thomas AN, Boxall EM, Laha SK, et al. An educational and audit tool to reduce prescribing error in intensive care. Qual Saf Health Care. 2008;17(5):360-3. doi:10.1136/qshc.2007.023242.
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psnet.ahrq.gov/issue/empowering-patients-and-supporting-health-care-providers-new-avenues-high-quality-care-and
June 23, 2021 - Special or Theme Issue
Empowering Patients and Supporting Health Care Providers—New Avenues for High Quality Care and Safety.
Citation Text:
Empowering Patients and Supporting Health Care Providers—New Avenues for High Quality Care and Safety. Rimondini M, Busch IM, eds. Int J Envir…
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psnet.ahrq.gov/issue/building-culture-safety-ophthalmology
March 14, 2022 - Commentary
Building a culture of safety in ophthalmology.
Citation Text:
Custer PL, Fitzgerald ME, Herman DC, et al. Building a Culture of Safety in Ophthalmology. Ophthalmology. 2016;123(9 Suppl):S40-5. doi:10.1016/j.ophtha.2016.06.019.
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psnet.ahrq.gov/issue/safety-issues-combined-gynecologic-and-plastic-surgical-procedures
January 06, 2018 - Review
Safety issues in combined gynecologic and plastic surgical procedures.
Citation Text:
Kryger ZB, Dumanian GA, Howard MA. Safety issues in combined gynecologic and plastic surgical procedures. Int J Gynaecol Obstet. 2007;99(3):257-63.
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psnet.ahrq.gov/issue/5th-anniversary-universal-protocol-pitfalls-and-pearls-revisited
December 21, 2014 - Commentary
The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited.
Citation Text:
Stahel PF, Mehler PS, Clarke TJ, et al. The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited. Patient Saf Surg. 2009;3(1):14. doi:10.1186/1754-9493-3-14. …
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psnet.ahrq.gov/issue/clinical-decision-making-heuristics-and-cognitive-biases-ophthalmologist
November 01, 2023 - Review
Clinical decision-making: heuristics and cognitive biases for the ophthalmologist.
Citation Text:
Hussain A, Oestreicher J. Clinical decision-making: heuristics and cognitive biases for the ophthalmologist. Surv Ophthalmol. 2018;63(1):119-124. doi:10.1016/j.survophthal.2017.08.007…
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psnet.ahrq.gov/issue/facilitating-and-impeding-factors-physicians-error-disclosure-structured-literature-review
September 12, 2011 - Review
Facilitating and impeding factors for physicians' error disclosure: a structured literature review.
Citation Text:
Kaldjian LC, Jones EW, Rosenthal GE. Facilitating and impeding factors for physicians' error disclosure: a structured literature review. Jt Comm J Qual Patient Saf. 2…
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psnet.ahrq.gov/issue/three-simple-rules-improve-medication-safety
March 11, 2020 - Commentary
Three simple rules to improve medication safety.
Citation Text:
Barba V. Three Simple Rules to Improve Medication Safety. J Patient Saf. 2016;12(3):171-2. doi:10.1097/PTS.0000000000000095.
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psnet.ahrq.gov/issue/quantification-surgical-resident-stress-call
August 26, 2011 - Study
Quantification of surgical resident stress "on call".
Citation Text:
Tendulkar AP, Victorino GP, Chong TJ, et al. Quantification of surgical resident stress "on call". J Am Coll Surg. 2005;201(4):560-4.
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psnet.ahrq.gov/issue/patient-safety-instruction-us-health-professions-education
September 01, 2015 - Review
Patient safety instruction in US health professions education.
Citation Text:
Kiersma ME, Plake KS, Darbishire PL. Patient safety instruction in US health professions education. Am J Pharm Educ. 2011;75(8):162. doi:10.5688/ajpe758162.
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psnet.ahrq.gov/issue/bearing-witness-ethics-practice-storying-physicians-medical-mistake-narratives
July 17, 2024 - Study
Bearing witness to the ethics of practice: storying physicians' medical mistake narratives.
Citation Text:
Carmack HJ. Bearing witness to the ethics of practice: storying physicians' medical mistake narratives. Health Commun. 2010;25(5):449-58. doi:10.1080/10410236.2010.484876.
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psnet.ahrq.gov/issue/importance-failing-forward-all-us-will-fail-and-make-mistakes-how-can-they-benefit-us-and-our
July 27, 2016 - Newspaper/Magazine Article
The importance of failing forward. All of us will fail and make mistakes, but how can they benefit us and our organizations?
Citation Text:
Hofmann PB. The importance of failing forward. All of us will fail and make mistakes, but how can they benefit us and ou…
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psnet.ahrq.gov/web-mm/turn-other-cheek
October 26, 2010 - Outcome of 6 years of protocol use for preventing wrong site office surgery. … February 10, 2012
Outcome of 6 years of protocol use for preventing wrong site office … August 2, 2015
Outcome of 6 years of protocol use for preventing wrong site office surgery
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psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - studies cite practitioner communication
skills as a factor in malpractice.(1,2) Furthermore, the tragic outcome … /psnet.ahrq.gov/web-mm/hard-swallow
https://psnet.ahrq.gov//#references
were made NPO pending the outcome … clinicians at the time, could have led to follow-up actions to mitigate or avert an
adverse patient outcome
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psnet.ahrq.gov/node/49833/psn-pdf
June 01, 2018 - challenges us to
review potential system and cognitive factors that could have contributed to this outcome … This case represents the treatment of a stroke mimic or misdiagnosis that contributed to an adverse
outcome … Association of outcome with early stroke treatment: pooled
analysis of ATLANTIS, ECASS, and NINDS rt-PA
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psnet.ahrq.gov/web-mm/refused-medication-error
November 01, 2005 - is problematic on many levels, this commentary focuses on the three likely causes of the unfortunate outcome … transfer can be discussed and improved upon.( 11 ) Several best practices might have led to a different outcome … overcome those barriers to effectively communicate.( 7 ) Such practices might have led to a better outcome