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psnet.ahrq.gov/issue/fractures-fingers-missed-or-misdiagnosed-poorly-positioned-or-poorly-taken-radiographs
September 07, 2022 - Study
Fractures of the fingers missed or misdiagnosed on poorly positioned or poorly taken radiographs: a retrospective study.
Citation Text:
Tuncer S, Aksu N, Dilek H, et al. Fractures of the fingers missed or misdiagnosed on poorly positioned or poorly taken radiographs: a retrospect…
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psnet.ahrq.gov/issue/ins-and-outs-change-shift-handoffs-between-nurses-communication-challenge
October 19, 2022 - Study
The ins and outs of change of shift handoffs between nurses: a communication challenge.
Citation Text:
Carroll JS, Williams M, Gallivan TM. The ins and outs of change of shift handoffs between nurses: a communication challenge. BMJ Qual Saf. 2012;21(7):586-93. doi:10.1136/bmjqs-2…
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psnet.ahrq.gov/issue/medication-safety-program-reduces-adverse-drug-events-community-hospital
April 24, 2018 - Study
Medication safety program reduces adverse drug events in a community hospital.
Citation Text:
Cohen MM, Kimmel NL, Benage MK, et al. Medication safety program reduces adverse drug events in a community hospital. Qual Saf Health Care. 2005;14(3):169-74.
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psnet.ahrq.gov/issue/pharmacist-work-stress-and-learning-quality-related-events
January 07, 2016 - Study
Pharmacist work stress and learning from quality related events.
Citation Text:
Boyle TA, Bishop A, Morrison B, et al. Pharmacist work stress and learning from quality related events. Res Social Adm Pharm. 2016;12(5):772-83. doi:10.1016/j.sapharm.2015.10.003.
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psnet.ahrq.gov/issue/clinical-scenarios-enhancing-skill-set-nurse-vigilant-guardian
July 19, 2023 - Study
Clinical scenarios: enhancing the skill set of the nurse as a vigilant guardian.
Citation Text:
Jacobson T, Belcher E, Sarr B, et al. Clinical scenarios: enhancing the skill set of the nurse as a vigilant guardian. J Contin Educ Nurs. 2010;41(8):347-53; quiz 354-5. doi:10.3928/0…
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psnet.ahrq.gov/issue/acceptance-recommendations-inpatient-pharmacy-case-managers-unintended-consequences
November 16, 2022 - Study
Acceptance of recommendations by inpatient pharmacy case managers: unintended consequences of hospitalist and specialist care.
Citation Text:
Anderegg S, Demik DE, Carter BL, et al. Acceptance of recommendations by inpatient pharmacy case managers: unintended consequences of hosp…
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psnet.ahrq.gov/issue/randomized-controlled-trial-effect-double-check-detection-medication-errors
June 07, 2016 - Study
A randomized controlled trial on the effect of a double check on the detection of medication errors.
Citation Text:
Douglass AM, Elder J, Watson R, et al. A Randomized Controlled Trial on the Effect of a Double Check on the Detection of Medication Errors. Ann Emerg Med. 2018;71(1):…
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psnet.ahrq.gov/issue/use-specific-indicators-detect-warfarin-related-adverse-events
October 19, 2022 - Study
Use of specific indicators to detect warfarin-related adverse events.
Citation Text:
Hartis CE, Gum MO, Lederer JW. Use of specific indicators to detect warfarin-related adverse events. American Journal of Health-System Pharmacy. 2005;62(16). doi:10.2146/ajhp040404.
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psnet.ahrq.gov/issue/exploring-varieties-knowledge-safe-work-practices-ethnographic-study-surgical-teams
December 21, 2016 - Study
Exploring varieties of knowledge in safe work practices—an ethnographic study of surgical teams.
Citation Text:
Høyland S, Aase K, Hollund JG. Exploring varieties of knowledge in safe work practices - an ethnographic study of surgical teams. Patient Saf Surg. 2011;5:21. doi:10.11…
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psnet.ahrq.gov/issue/risk-adverse-drug-events-patient-destination-after-hospital-discharge
March 04, 2020 - Study
Risk of adverse drug events by patient destination after hospital discharge.
Citation Text:
Triller DM, Clause SL, Hamilton RA. Risk of adverse drug events by patient destination after hospital discharge. Am J Health Syst Pharm. 2005;62(18):1883-9.
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psnet.ahrq.gov/issue/development-and-implementation-oral-sign-out-skills-curriculum
February 15, 2011 - Commentary
Development and implementation of an oral sign-out skills curriculum.
Citation Text:
Horwitz LI, Moin T, Green M. Development and implementation of an oral sign-out skills curriculum. J Gen Intern Med. 2007;22(10):1470-4.
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psnet.ahrq.gov/issue/medication-errors-use-allopurinol-and-colchicine-retrospective-study-national-anonymous
December 21, 2014 - Study
Medication errors with the use of allopurinol and colchicine: a retrospective study of a national, anonymous Internet-accessible error reporting system.
Citation Text:
Mikuls TR, Curtis JR, Allison JJ, et al. Medication errors with the use of allopurinol and colchicine: a retrosp…
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psnet.ahrq.gov/issue/medication-errors-important-component-nonadherence-medication-outpatient-population-lung
June 23, 2021 - Study
Medication errors: an important component of nonadherence to medication in an outpatient population of lung transplant recipients.
Citation Text:
Irani S, Seba P, Speich R, et al. Medication errors: an important component of nonadherence to medication in an outpatient population …
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psnet.ahrq.gov/issue/use-simulation-assess-electronic-health-record-safety-intensive-care-unit-pilot-study
December 10, 2014 - Study
Use of simulation to assess electronic health record safety in the intensive care unit: a pilot study.
Citation Text:
March CA, Steiger D, Scholl G, et al. Use of simulation to assess electronic health record safety in the intensive care unit: a pilot study. BMJ Open. 2013;3(4). d…
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psnet.ahrq.gov/issue/scope-drug-related-problems-home-care-setting
February 16, 2011 - Review
The scope of drug-related problems in the home care setting.
Citation Text:
Meyer-Massetti C, Meier CR, Guglielmo J. The scope of drug-related problems in the home care setting. Int J Clin Pharm. 2018;40(2):325-334. doi:10.1007/s11096-017-0581-9.
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psnet.ahrq.gov/issue/timely-follow-abnormal-outpatient-test-results-perceived-barriers-and-impact-patient-safety
August 02, 2010 - Study
Timely follow-up of abnormal outpatient test results: perceived barriers and impact on patient safety.
Citation Text:
Moore C, Saigh O, Trikha A, et al. Timely Follow-Up of Abnormal Outpatient Test Results. J Patient Saf. 2008;4(4):241-244. doi:10.1097/pts.0b013e31818d1ca4.
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psnet.ahrq.gov/issue/opioid-prescribing-after-surgical-extraction-teeth-medicaid-patients-2000-2010
March 02, 2011 - Study
Opioid prescribing after surgical extraction of teeth in Medicaid patients, 2000–2010.
Citation Text:
Baker JA, Avorn J, Levin R, et al. Opioid Prescribing After Surgical Extraction of Teeth in Medicaid Patients, 2000-2010. JAMA. 2016;315(15):1653-4. doi:10.1001/jama.2015.19058.
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psnet.ahrq.gov/issue/evaluation-and-certification-computerized-physician-order-entry-systems
May 27, 2011 - Review
Evaluation and certification of computerized physician order entry systems.
Citation Text:
Classen D, Avery A, Bates DW. Evaluation and certification of computerized provider order entry systems. J Am Med Inform Assoc. 2007;14(1):48-55.
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psnet.ahrq.gov/issue/safety-culture-and-care-program-prevent-surgical-errors
March 25, 2020 - Commentary
Safety culture and care: a program to prevent surgical errors.
Citation Text:
Hemingway MW, O'Malley C, Silvestri S. Safety culture and care: a program to prevent surgical errors. AORN J. 2015;101(4):404-12; quiz 413-5. doi:10.1016/j.aorn.2015.01.002.
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psnet.ahrq.gov/issue/real-time-debriefing-after-critical-events-exploring-gap-between-principle-and-reality
December 15, 2021 - Review
Emerging Classic
Real-time debriefing after critical events: exploring the gap between principle and reality.
Citation Text:
Arriaga AF, Szyld D, Pian-Smith MCM. Real-time debriefing after critical events: exploring the gap between principle and reality. …