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psnet.ahrq.gov/issue/2016-updated-american-society-clinical-oncologyoncology-nursing-society-chemotherapy
February 15, 2023 - Commentary
2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, including standards for pediatric oncology.
Citation Text:
Belderson KM, Billett AL. Chemotherapy safety standards: A pediatric perspective. J Oncol Pract.…
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psnet.ahrq.gov/issue/medication-prescribing-errors-teaching-hospital
December 23, 2008 - Study
Classic
Medication prescribing errors in a teaching hospital.
Citation Text:
Lesar TS, Briceland LL, Delcoure K, et al. Medication prescribing errors in a teaching hospital. JAMA. 1990;263(17):2329-34.
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psnet.ahrq.gov/issue/successful-use-rapid-response-team-pediatric-oncology-outpatient-setting
December 21, 2016 - Commentary
Successful use of a rapid response team in the pediatric oncology outpatient setting.
Citation Text:
Avent Y, Johnson S, Henderson N, et al. Successful use of a rapid response team in the pediatric oncology outpatient setting. Jt Comm J Qual Patient Saf. 2010;36(1):43-5.
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psnet.ahrq.gov/issue/diagnostic-errors-and-abnormal-diagnostic-tests-lost-follow-source-needless-waste-and-delay
December 22, 2008 - Commentary
Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment.
Citation Text:
Wahls TL. Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment. J Ambul Care M…
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psnet.ahrq.gov/issue/accreditation-council-graduate-medical-education-technical-skills-competency-compliance
November 16, 2022 - Study
Accreditation Council on Graduate Medical Education technical skills competency compliance: urologic surgical skills.
Citation Text:
Hammond L, Ketchum J, Schwartz BF. Accreditation Council on Graduate Medical Education Technical Skills Competency Compliance: Urologic Surgical Sk…
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psnet.ahrq.gov/issue/do-team-processes-really-have-effect-clinical-performance-systematic-literature-review
November 13, 2019 - Review
Do team processes really have an effect on clinical performance? A systematic literature review.
Citation Text:
Schmutz J, Manser T. Do team processes really have an effect on clinical performance? A systematic literature review. Br J Anaesth. 2013;110(4). doi:10.1093/bja/aes513.…
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psnet.ahrq.gov/issue/changing-conversations-teaching-safety-and-quality-residency-training
January 02, 2017 - Study
Changing conversations: teaching safety and quality in residency training.
Citation Text:
Voss JD, May NB, Schorling JB, et al. Changing conversations: teaching safety and quality in residency training. Acad Med. 2008;83(11):1080-7. doi:10.1097/ACM.0b013e31818927f8.
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psnet.ahrq.gov/issue/we-are-going-name-names-and-call-you-out-improving-team-academic-operating-room-environment
September 23, 2020 - Study
We are going to name names and call you out! Improving the team in the academic operating room environment.
Citation Text:
Bodor R, Nguyen BJ, Broder K. We Are Going to Name Names and Call You Out! Improving the Team in the Academic Operating Room Environment. Ann Plast Surg. 2017;…
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psnet.ahrq.gov/issue/beyond-medical-record-other-modes-error-acknowledgment
August 03, 2009 - Study
Beyond the medical record: other modes of error acknowledgment.
Citation Text:
Rosenthal M, Cornett PL, Sutcliffe K, et al. Beyond the medical record: other modes of error acknowledgment. J Gen Intern Med. 2005;20(5):404-9.
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psnet.ahrq.gov/issue/secure-messaging-use-and-wrong-patient-ordering-errors-among-inpatient-clinicians
July 20, 2022 - Study
Secure messaging use and wrong-patient ordering errors among inpatient clinicians.
Citation Text:
Lou SS, Lew D, Xia L, et al. Secure messaging use and wrong-patient ordering errors among inpatient clinicians. JAMA Netw Open. 2024;7(12):e2447797. doi:10.1001/jamanetworkopen.2024.47…
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psnet.ahrq.gov/issue/are-med-school-grads-prepared-practice-medicine
April 04, 2012 - Newspaper/Magazine Article
Are med school grads prepared to practice medicine?
Citation Text:
Angus S, Vu R, Halvorsen AJ, et al. What skills should new internal medicine interns have in july? A national survey of internal medicine residency program directors. Academic medicine : journal…
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psnet.ahrq.gov/issue/quality-and-health-system-becoming-high-reliability-organization
November 16, 2022 - Review
Quality and the health system: becoming a high reliability organization.
Citation Text:
Gaw M, Rosinia F, Diller T. Quality and the health system: becoming a high reliability organization. Anesthesiol Clin. 2018;36(2):217-226. doi:10.1016/j.anclin.2018.01.010.
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psnet.ahrq.gov/issue/failures-communication-and-information-transfer-across-surgical-care-pathway-interview-study
August 09, 2013 - Study
Failures in communication and information transfer across the surgical care pathway: interview study.
Citation Text:
Nagpal K, Arora S, Vats A, et al. Failures in communication and information transfer across the surgical care pathway: interview study. BMJ Qual Saf. 2012;21(10):8…
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psnet.ahrq.gov/issue/improving-patient-safety-and-optimizing-nursing-teamwork-using-crew-resource-management
March 13, 2013 - Study
Improving patient safety and optimizing nursing teamwork using crew resource management techniques.
Citation Text:
West P, Sculli GL, Fore AM, et al. Improving patient safety and optimizing nursing teamwork using crew resource management techniques. J Nurs Adm. 2012;42(1):15-20. do…
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psnet.ahrq.gov/issue/diagnostic-error-critically-ill-defining-problem-and-exploring-next-steps-advance-intensive
January 24, 2024 - Commentary
Diagnostic error in the critically ill: defining the problem and exploring next steps to advance intensive care unit safety.
Citation Text:
Bergl PA, Nanchal RS, Singh H. Diagnostic Error in the Critically III: Defining the Problem and Exploring Next Steps to Advance Intensive…
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psnet.ahrq.gov/issue/sins-omission-getting-too-little-medical-care-may-be-greatest-threat-patient-safety
March 06, 2005 - Study
Sins of omission. Getting too little medical care may be the greatest threat to patient safety.
Citation Text:
Hayward RA, Asch SM, Hogan MM, et al. Sins of omission: getting too little medical care may be the greatest threat to patient safety. J Gen Intern Med. 2005;20(8):686-91…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - judgment and errors in technique occurred, and the attending surgeon was ultimately responsible for the outcome … Approach to Improving Patient Safety
Errors in both judgement and technique led to this adverse outcome … understandings about the allowable number and location of cannulation attempts, could also have improved the outcome … Following these best practices could have resulted in a much better outcome for the patient in this case
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psnet.ahrq.gov/web-mm/pregnant-danger
January 12, 2011 - e.g., CT scan) might have detected the aortic dissection before the discharge and subsequent tragic outcome … The mother and fetus in this case suffered a tragic outcome at a hospital that appeared to lack a structured … It is unclear whether the outcome would have been different elsewhere. … Aortic dissection in pregnancy: analysis of risk factors and outcome.
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
Luckily, this case has a good outcome … student or practicing team level through critical incident root cause analysis and
http://www.acgme.org/outcome … Available at:
http://www.acgme.org/outcome/. Accessed September 27, 2007.
13. … cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9032162
http://www.acgme.org/outcome/
http://www.ama-assn.org
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psnet.ahrq.gov/issue/effectiveness-toyota-process-redesign-reducing-thyroid-gland-fine-needle-aspiration-error
June 14, 2011 - June 14, 2011
Frequency and outcome of cervical cancer prevention failures in the United