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psnet.ahrq.gov/issue/reducing-medication-errors-using-applied-technology
January 07, 2011 - Commentary
Reducing medication errors by using applied technology.
Citation Text:
Caesar BR, Hutchinson B. Reducing medication errors by using applied technology. Nursing (Brux). 2006;36(8):24-25.
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psnet.ahrq.gov/issue/creating-just-culture-ottawa-hospitals-experience
July 10, 2024 - Commentary
Creating a just culture: the Ottawa Hospital's experience.
Citation Text:
Forster AJ, Hamilton S, Hayes T, et al. Creating a Just Culture: The Ottawa Hospital's experience. Healthc Manage Forum. 2019;32(5):266-271. doi:10.1177/0840470419853303.
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psnet.ahrq.gov/issue/pre-surgery-briefings-and-safety-climate-operating-theatre
September 27, 2016 - Study
Pre-surgery briefings and safety climate in the operating theatre.
Citation Text:
Allard J, Bleakley A, Hobbs A, et al. Pre-surgery briefings and safety climate in the operating theatre. BMJ Qual Saf. 2011;20(8):711-7. doi:10.1136/bmjqs.2009.032672.
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psnet.ahrq.gov/issue/prevention-fatal-opioid-overdose
October 03, 2018 - Commentary
Prevention of fatal opioid overdose.
Citation Text:
Beletsky L, Rich JD, Walley AY. Prevention of fatal opioid overdose. JAMA. 2012;308(18):1863-4. doi:10.1001/jama.2012.14205.
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psnet.ahrq.gov/issue/detecting-adverse-drug-events-through-data-mining
February 17, 2009 - Commentary
Detecting adverse drug events through data mining.
Citation Text:
Glasgow JM, Kaboli PJ. Detecting adverse drug events through data mining. Am J Health Syst Pharm. 2010;67(4):317-20. doi:10.2146/ajhp090115.
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psnet.ahrq.gov/issue/inpatient-notes-reducing-diagnostic-error-new-horizon-opportunities-hospital-medicine
February 24, 2021 - Commentary
Inpatient notes: reducing diagnostic error—a new horizon of opportunities for hospital medicine.
Citation Text:
Singh H, Zwaan L. Web Exclusives. Annals for Hospitalists Inpatient Notes - Reducing Diagnostic Error-A New Horizon of Opportunities for Hospital Medicine. Ann Inter…
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psnet.ahrq.gov/issue/analysis-laboratory-critical-value-reporting-large-academic-medical-center
December 05, 2013 - Study
Analysis of laboratory critical value reporting at a large academic medical center.
Citation Text:
Dighe AS, Rao A, Coakley AB, et al. Analysis of laboratory critical value reporting at a large academic medical center. Am J Clin Pathol. 2006;125(5):758-64.
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psnet.ahrq.gov/issue/cluster-randomized-clinical-trial-improve-prescribing-patterns-ambulatory-pediatrics
April 04, 2011 - Study
A cluster randomized clinical trial to improve prescribing patterns in ambulatory pediatrics.
Citation Text:
Davis RL, Wright J, Chalmers F, et al. A cluster randomized clinical trial to improve prescribing patterns in ambulatory pediatrics. PLoS Clin Trials. 2007;2(5):e25.
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psnet.ahrq.gov/issue/interdisciplinary-collaboration-maintain-culture-safety-labor-and-delivery-setting
January 02, 2017 - Commentary
Interdisciplinary collaboration to maintain a culture of safety in a labor and delivery setting.
Citation Text:
Burke C, Grobman WA, Miller D. Interdisciplinary collaboration to maintain a culture of safety in a labor and delivery setting. J Perinat Neonatal Nurs. 2013;27(2):…
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psnet.ahrq.gov/issue/public-reporting-patient-safety-metrics-ready-or-not
July 14, 2010 - Commentary
Public reporting of patient safety metrics: ready or not?
Citation Text:
Podolsky DK, Nagarkar PA, Reed G, et al. Public reporting of patient safety metrics: ready or not? Plast Reconstr Surg. 2014;134(6):981e-5e. doi:10.1097/PRS.0000000000000713.
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psnet.ahrq.gov/issue/medication-reconciliation-emergency-department-opportunities-workflow-redesign
August 04, 2021 - Commentary
Medication reconciliation in the emergency department: opportunities for workflow redesign.
Citation Text:
Hummel J, Evans PC, Lee H. Medication reconciliation in the emergency department: opportunities for workflow redesign. Qual Saf Health Care. 2010;19(6):531-5. doi:10.11…
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psnet.ahrq.gov/issue/nursing-student-medication-errors-case-study-using-root-cause-analysis
November 16, 2022 - Commentary
Nursing student medication errors: a case study using root cause analysis.
Citation Text:
Dolansky MA, Druschel K, Helba M, et al. Nursing student medication errors: a case study using root cause analysis. J Prof Nurs. 2013;29(2):102-8. doi:10.1016/j.profnurs.2012.12.010.
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psnet.ahrq.gov/issue/high-fidelity-simulation-based-training-neonatal-nursing
April 11, 2011 - Study
High fidelity simulation-based training in neonatal nursing.
Citation Text:
Yaeger KA, Halamek LP, Coyle M, et al. High-fidelity simulation-based training in neonatal nursing. Adv Neonatal Care. 2004;4(6):326-31.
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psnet.ahrq.gov/issue/measuring-errors-surgical-pathology-real-life-practice-defining-what-does-and-does-not-matter
January 14, 2011 - Review
Measuring errors in surgical pathology in real-life practice: defining what does and does not matter.
Citation Text:
Renshaw AA, Gould EW. Measuring errors in surgical pathology in real-life practice: defining what does and does not matter. Am J Clin Pathol. 2007;127(1):144-52. …
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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
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psnet.ahrq.gov/issue/usability-study-two-common-defibrillators-reveals-hazards
June 16, 2009 - September 30, 2010
EMS helicopter crashes: what influences fatal outcome?
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psnet.ahrq.gov/issue/sages-fuse-program-bridging-patient-safety-gap
April 05, 2017 - June 7, 2018
Fatal outcome after inadvertent injection of topical epinephrine.