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psnet.ahrq.gov/issue/epidemiology-prescribing-errors-potential-impact-computerized-prescriber-order-entry
May 04, 2010 - Study
The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry.
Citation Text:
Bobb A, Gleason KM, Husch M, et al. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med. 2004;164(7…
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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/unintentionally-retained-guidewires-descriptive-study-73-sentinel-events
April 27, 2019 - Study
Unintentionally retained guidewires: a descriptive study of 73 sentinel events.
Citation Text:
Steelman VM, Thenuwara K, Shaw C, et al. Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events. Jt Comm J Qual Saf. 2019;45(2):81-90. doi:10.1016/j.jcjq.2018.08.0…
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psnet.ahrq.gov/issue/designing-safer-process-prevent-retained-surgical-sponges-healthcare-failure-mode-and-effect
April 27, 2019 - Study
Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis.
Citation Text:
Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J. 2011;94(2):1…
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psnet.ahrq.gov/issue/when-err-inhuman-examination-influence-artificial-intelligence-driven-nursing-care-patient
October 19, 2022 - Commentary
When to err is inhuman: an examination of the influence of artificial intelligence-driven nursing care on patient safety.
Citation Text:
Johnson EA, Dudding KM, Carrington JM. When to err is inhuman: an examination of the influence of artificial intelligence‐driven nursing car…
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psnet.ahrq.gov/issue/detection-and-measurement-rotator-cuff-tears-sonography-analysis-diagnostic-errors
December 31, 2014 - Study
Detection and measurement of rotator cuff tears with sonography: analysis of diagnostic errors.
Citation Text:
Teefey SA, Middleton WD, Payne WT, et al. Detection and measurement of rotator cuff tears with sonography: analysis of diagnostic errors. AJR Am J Roentgenol. 2005;184(6…
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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/nursephysician-communication-through-sensemaking-lens-shifting-paradigm-improve-patient
June 05, 2024 - Review
Nurse/physician communication through a sensemaking lens: shifting the paradigm to improve patient safety.
Citation Text:
Manojlovich M. Nurse/physician communication through a sensemaking lens: shifting the paradigm to improve patient safety. Med Care. 2010;48(11):941-6. doi:10…
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psnet.ahrq.gov/issue/what-did-doctor-say-health-literacy-and-recall-medical-instructions
December 21, 2014 - Study
What did the doctor say? Health literacy and recall of medical instructions.
Citation Text:
McCarthy D, Waite KR, Curtis LM, et al. What did the doctor say? Health literacy and recall of medical instructions. Med Care. 2012;50(4):277-82. doi:10.1097/MLR.0b013e318241e8e1.
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psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-awards-advocacy-lexington-veterans-affairs-medical-center
March 02, 2011 - Commentary
John M. Eisenberg Patient Safety Awards. Advocacy: the Lexington Veterans Affairs Medical Center.
Citation Text:
Kraman SS, Cranfill L, Hamm G, et al. John M. Eisenberg Patient Safety Awards. Advocacy: the Lexington Veterans Affairs Medical Center. Jt Comm J Qual Improv. 2002;…
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psnet.ahrq.gov/issue/kadcyla-ado-trastuzumab-emtansine-drug-safety-communication-potential-medication-errors
October 09, 2013 - Press Release/Announcement
Kadcyla (ado-trastuzumab emtansine): drug safety communication—potential medication errors resulting from name confusion.
Citation Text:
Kadcyla (ado-trastuzumab emtansine): drug safety communication—potential medication errors resulting from name confusion. …
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psnet.ahrq.gov/issue/world-health-organization-5-moments-hand-hygiene-scientific-foundation
October 19, 2022 - Commentary
The World Health Organization '5 moments of hand hygiene': the scientific foundation.
Citation Text:
Chou DTS, Achan P, Ramachandran M. The World Health Organization '5 moments of hand hygiene': the scientific foundation. J Bone Joint Surg Br. 2012;94(4):441-5. doi:10.1302/0…
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psnet.ahrq.gov/issue/systematic-error-and-cognitive-bias-obstetric-ultrasound
December 13, 2023 - Commentary
Systematic error and cognitive bias in obstetric ultrasound.
Citation Text:
Sotiriadis A, Odibo AO. Systematic error and cognitive bias in obstetric ultrasound. Ultrasound Obstet Gynecol. 2019;53(4):431-435. doi:10.1002/uog.20232.
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psnet.ahrq.gov/issue/perceptions-preventable-medical-errors-alberta-canada
January 21, 2019 - Study
Perceptions of preventable medical errors in Alberta, Canada.
Citation Text:
Northcott H, Vanderheyden L, Northcott J, et al. Perceptions of preventable medical errors in Alberta, Canada. Int J Qual Health Care. 2007;20(2):115-122. doi:10.1093/intqhc/mzm067.
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psnet.ahrq.gov/issue/inpatient-notes-just-what-doctor-ordered-checklists-improve-diagnosis
August 14, 2019 - Commentary
Inpatient notes: just what the doctor ordered—checklists to improve diagnosis.
Citation Text:
Gupta A, Graber ML. Web Exclusive. Annals for Hospitalists Inpatient Notes - Just What the Doctor Ordered-Checklists to Improve Diagnosis. Ann Intern Med. 2019;170(8):HO2-HO3. doi:10.…
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psnet.ahrq.gov/issue/nature-causes-and-consequences-unintended-events-surgical-units
September 07, 2016 - Study
Nature, causes and consequences of unintended events in surgical units.
Citation Text:
van Wagtendonk I, Smits M, Merten H, et al. Nature, causes and consequences of unintended events in surgical units. Br J Surg. 2010;97(11):1730-40. doi:10.1002/bjs.7201.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-sbs.pdf
June 02, 2025 - NICU Family Information Packet, Appendix B, Short Bowel Syndrome
Short Bowel Syndrome
Pathophysiology
■ Functional disorder caused by alterations of normal intestinal anatomy and physiology.
■ Shortened bowel combined with malabsorption; dependent on parenteral nutrition >3 months.
■ May result from: necrotizin…
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psnet.ahrq.gov/issue/relationship-incorrect-dosing-fibrinolytic-therapy-and-clinical-outcomes
November 10, 2015 - Study
Relationship of incorrect dosing of fibrinolytic therapy and clinical outcomes.
Citation Text:
Mehta RH. Relationship of Incorrect Dosing of Fibrinolytic Therapy and Clinical Outcomes. JAMA. 2005;293(14). doi:10.1001/jama.293.14.1746.
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psnet.ahrq.gov/issue/shifting-learning-curve
March 09, 2009 - Commentary
Shifting the learning curve.
Citation Text:
Reynolds T, Kong M-L. Shifting the learning curve. BMJ. 2010;341:c6260. doi:10.1136/bmj.c6260.
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psnet.ahrq.gov/issue/admission-handoff-communications-clinicians-shared-understanding-patient-severity-illness-and
May 31, 2017 - Study
Admission handoff communications: clinician's shared understanding of patient severity of illness and problems.
Citation Text:
Brannen M, Cameron KA, Adler MD, et al. Admission Handoff Communications. J Patient Saf. 2009;5(4). doi:10.1097/pts.0b013e3181c029e5.
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