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  1. A necessary sea change for nurse faculty development: spotlight on quality and safety. | PSNet

    psnet.ahrq.gov/issue/necessary-sea-change-nurse-faculty-development-spotlight-quality-and-safety
    May 25, 2011 - Commentary A necessary sea change for nurse faculty development: spotlight on quality and safety. Citation Text: Thornlow D, McGuinn K. A necessary sea change for nurse faculty development: spotlight on quality and safety. J Prof Nurs. 2010;26(2):71-81. doi:10.1016/j.profnurs.2009.10.00…

  2. Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults. | PSNet

    psnet.ahrq.gov/issue/cascade-iatrogenesis-factors-leading-development-adverse-events-hospitalized-older-adults
    June 27, 2012 - Commentary Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults. Citation Text: Thornlow D, Anderson RA, Oddone E. Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults. Int J Nurs Stud…

  3. Improving Papanicolaou test quality and reducing medical errors by using Toyota production system methods. | PSNet

    psnet.ahrq.gov/issue/improving-papanicolaou-test-quality-and-reducing-medical-errors-using-toyota-production
    April 08, 2008 - Study Improving Papanicolaou test quality and reducing medical errors by using Toyota production system methods. Citation Text: Raab SS, Andrew-JaJa C, Condel JL, et al. Improving Papanicolaou test quality and reducing medical errors by using Toyota production system methods. Am J Obst…

  4. The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process.  | PSNet

    psnet.ahrq.gov/issue/hospital-discharge-review-high-risk-care-transition-highlights-reengineered-discharge-process
    December 16, 2014 - Study The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process.  Citation Text: Greenwald JL, Denham CR, Jack BW. The Hospital Discharge. J Patient Saf. 2008;3(2). doi:10.1097/01.jps.0000236916.94696.12. Copy Citation For…

  5. Usability study of two common defibrillators reveals hazards. | PSNet

    psnet.ahrq.gov/issue/usability-study-two-common-defibrillators-reveals-hazards
    June 16, 2009 - Study Usability study of two common defibrillators reveals hazards. Citation Text: Fairbanks RJ, Caplan SH, Bishop PA, et al. Usability Study of Two Common Defibrillators Reveals Hazards. Ann Emerg Med. 2007;50(4):424-432. doi:10.1016/j.annemergmed.2007.03.029. Copy Citation Form…

  6. "Second victim" casualties and how physician leaders can help. | PSNet

    psnet.ahrq.gov/issue/second-victim-casualties-and-how-physician-leaders-can-help
    August 28, 2024 - Newspaper/Magazine Article "Second victim" casualties and how physician leaders can help. Citation Text: MacLeod L. "Second victim" casualties and how physician leaders can help. Physician Exect. 2014;40(1):8-12. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X…

  7. Year in review: medication mishaps in the elderly. | PSNet

    psnet.ahrq.gov/issue/year-review-medication-mishaps-elderly
    August 15, 2012 - Review Year in review: medication mishaps in the elderly. Citation Text: Peron EP, Marcum ZA, Boyce R, et al. Year in review: medication mishaps in the elderly. Am J Geriatr Pharmacother. 2011;9(1):1-10. doi:10.1016/j.amjopharm.2011.01.003. Copy Citation Format: DOI Googl…

  8. Medication-related patient safety incidents in critical care: a review of reports to the UK National Patient Safety Agency. | PSNet

    psnet.ahrq.gov/issue/medication-related-patient-safety-incidents-critical-care-review-reports-uk-national-patient
    December 02, 2009 - Study Medication-related patient safety incidents in critical care: a review of reports to the UK National Patient Safety Agency. Citation Text: Thomas AN, Panchagnula U. Medication-related patient safety incidents in critical care: a review of reports to the UK National Patient Safety…

  9. Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge. | PSNet

    psnet.ahrq.gov/issue/medication-reconciliation-acute-care-ensuring-accurate-drug-regimen-admission-and-discharge
    October 28, 2020 - Commentary Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge. Citation Text: Rodehaver C, Fearing D. Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge. Jt Comm J Qual Patient Saf. 2005…

  10. Hospital RNs' experiences with disruptive behavior: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/hospital-rns-experiences-disruptive-behavior-qualitative-study
    September 09, 2015 - Study Hospital RNs' experiences with disruptive behavior: a qualitative study. Citation Text: Walrath JM, Dang D, Nyberg D. Hospital RNs' experiences with disruptive behavior: a qualitative study. J Nurs Care Qual. 2010;25(2):105-116. doi:10.1097/NCQ.0b013e3181c7b58e. Copy Citation …

  11. A work systems analysis approach to understanding fatigue in hospital nurses. | PSNet

    psnet.ahrq.gov/issue/work-systems-analysis-approach-understanding-fatigue-hospital-nurses
    July 08, 2020 - Study A work systems analysis approach to understanding fatigue in hospital nurses. Citation Text: Steege LM, Pasupathy KS, Drake DA. A work systems analysis approach to understanding fatigue in hospital nurses. Ergonomics. 2017;61(1):148-161. doi:10.1080/00140139.2017.1280186. Copy Ci…

  12. Studying critical values: adverse event identification following a critical laboratory values study at the Ohio State University Medical Center. | PSNet

    psnet.ahrq.gov/issue/studying-critical-values-adverse-event-identification-following-critical-laboratory-values
    September 01, 2018 - Study Studying critical values: adverse event identification following a critical laboratory values study at the Ohio State University Medical Center. Citation Text: Jenkins JJ, Crawford M, Bissell MG. Studying critical values: adverse event identification following a critical laborato…

  13. Overcoming human barriers to safety event reporting in radiology. | PSNet

    psnet.ahrq.gov/issue/overcoming-human-barriers-safety-event-reporting-radiology
    February 09, 2022 - Commentary Overcoming human barriers to safety event reporting in radiology. Citation Text: Siewert B, Brook OR, Swedeen S, et al. Overcoming Human Barriers to Safety Event Reporting in Radiology. Radiographics. 2019;39(1):251-263. doi:10.1148/rg.2019180135. Copy Citation Format: …

  14. Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs. | PSNet

    psnet.ahrq.gov/issue/safety-committees-need-proactively-address-risk-accidental-cerebral-injection-intravenous-iv
    January 27, 2021 - Newspaper/Magazine Article Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs. Citation Text: Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs. ISMP Medication …

  15. Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II. | PSNet

    psnet.ahrq.gov/issue/risk-evaluation-and-mitigation-strategy-rems-programs-and-medication-safety-parts-i-and-ii
    March 15, 2022 - Special or Theme Issue Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II. Citation Text: Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II. ISMP Medication Safety Alert! Acute care edition. July 13, 2…

  16. Opioid prescribing patterns and complications in the dermatology Medicare population. | PSNet

    psnet.ahrq.gov/issue/opioid-prescribing-patterns-and-complications-dermatology-medicare-population
    May 25, 2022 - Study Opioid prescribing patterns and complications in the dermatology Medicare population. Citation Text: Cao S, Karmouta R, Li DG, et al. Opioid Prescribing Patterns and Complications in the Dermatology Medicare Population. JAMA Dermatol. 2018;154(3):317-322. doi:10.1001/jamadermatol.2…

  17. Differences in day and night shift clinical performance in anesthesiology. | PSNet

    psnet.ahrq.gov/issue/differences-day-and-night-shift-clinical-performance-anesthesiology
    September 29, 2017 - Study Differences in day and night shift clinical performance in anesthesiology. Citation Text: Cao CGL, Weinger MB, Slagle JM, et al. Differences in day and night shift clinical performance in anesthesiology. Hum Factors. 2008;50(2):276-90. Copy Citation Format: Google S…

  18. More to teamwork than knowledge, skill and attitude. | PSNet

    psnet.ahrq.gov/issue/more-teamwork-knowledge-skill-and-attitude
    July 13, 2009 - Study More to teamwork than knowledge, skill and attitude. Citation Text: Siassakos D, Draycott TJ, Crofts JF, et al. More to teamwork than knowledge, skill and attitude. BJOG. 2010;117(10):1262-9. doi:10.1111/j.1471-0528.2010.02654.x. Copy Citation Format: DOI Google Sc…

  19. A system-wide initiative to prevent retained vaginal sponges. | PSNet

    psnet.ahrq.gov/issue/system-wide-initiative-prevent-retained-vaginal-sponges
    November 07, 2012 - Commentary A system-wide initiative to prevent retained vaginal sponges. Citation Text: Chagolla BA, Gibbs VC, Keats JP, et al. A system-wide initiative to prevent retained vaginal sponges. MCN Am J Matern Child Nurs. 2011;36(5):312-317. doi:10.1097/NMC.0b013e31822ab204. Copy Citatio…

  20. Balancing innovation and safety when integrating digital tools into health care. | PSNet

    psnet.ahrq.gov/issue/balancing-innovation-and-safety-when-integrating-digital-tools-health-care
    July 01, 2011 - Commentary Balancing innovation and safety when integrating digital tools into health care. Citation Text: Auerbach AD, Neinstein A, Khanna R. Balancing Innovation and Safety When Integrating Digital Tools Into Health Care. Ann Intern Med. 2018;168(10):733-734. doi:10.7326/M17-3108. Co…
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