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  1. Quality improvement and patient safety organizations in anesthesiology. | PSNet

    psnet.ahrq.gov/issue/quality-improvement-and-patient-safety-organizations-anesthesiology
    March 07, 2018 - Commentary Quality improvement and patient safety organizations in anesthesiology. Citation Text: Dutton RP. Quality improvement and patient safety organizations in anesthesiology. AMA J Ethics. 2015;17(3):248-52. doi:10.1001/journalofethics.2015.17.3.pfor1-1503. Copy Citation Form…

  2. Structural empowerment and patient safety culture among registered nurses working in adult critical care units. | PSNet

    psnet.ahrq.gov/issue/structural-empowerment-and-patient-safety-culture-among-registered-nurses-working-adult
    January 23, 2008 - Study Structural empowerment and patient safety culture among registered nurses working in adult critical care units. Citation Text: Armellino D, Griffin MTQ, Fitzpatrick JJ. Structural empowerment and patient safety culture among registered nurses working in adult critical care units.…

  3. Effect of critical access hospital conversion on patient safety. | PSNet

    psnet.ahrq.gov/issue/effect-critical-access-hospital-conversion-patient-safety
    October 19, 2022 - Study Effect of critical access hospital conversion on patient safety. Citation Text: Li P, Schneider JE, Ward MM. Effect of critical access hospital conversion on patient safety. Health Serv Res. 2007;42(6 Pt 1):2089-108; discussion 2294-323. Copy Citation Format: Google…

  4. Patient safety: examining the adequacy of the 5 rights of medication administration. | PSNet

    psnet.ahrq.gov/issue/patient-safety-examining-adequacy-5-rights-medication-administration
    March 02, 2016 - Commentary Patient safety: examining the adequacy of the 5 rights of medication administration. Citation Text: Macdonald M. Patient safety: examining the adequacy of the 5 rights of medication administration. Clin Nurse Spec. 2010;24(4):196-201. doi:10.1097/NUR.0b013e3181e3605f. Copy…

  5. Speaking up about the dangers of the hidden curriculum. | PSNet

    psnet.ahrq.gov/issue/speaking-about-dangers-hidden-curriculum
    September 30, 2020 - Commentary Speaking up about the dangers of the hidden curriculum. Citation Text: Liao JM, Thomas EJ, Bell SK. Speaking up about the dangers of the hidden curriculum. Health Aff (Millwood). 2014;33(1):168-171. doi:10.1377/hlthaff.2013.1073. Copy Citation Format: DOI Google…

  6. Error disclosure: a new domain for safety culture assessment. | PSNet

    psnet.ahrq.gov/issue/error-disclosure-new-domain-safety-culture-assessment
    September 01, 2018 - Study Error disclosure: a new domain for safety culture assessment. Citation Text: Etchegaray J, Gallagher TH, Bell SK, et al. Error disclosure: a new domain for safety culture assessment. BMJ Qual Saf. 2012;21(7):594-9. doi:10.1136/bmjqs-2011-000530. Copy Citation Format: …

  7. A study of the frequency and rationale for overriding allergy warnings in a computerized prescriber order entry system. | PSNet

    psnet.ahrq.gov/issue/study-frequency-and-rationale-overriding-allergy-warnings-computerized-prescriber-order-entry
    February 15, 2011 - Study A study of the frequency and rationale for overriding allergy warnings in a computerized prescriber order entry system. Citation Text: Swiderski SM, Pedersen CA, Schneider PJ, et al. A Study of the Frequency and Rationale for Overriding Allergy Warnings in a Computerized Prescrib…

  8. Use of a computerized forcing function improves performance in ordering restraints. | PSNet

    psnet.ahrq.gov/issue/use-computerized-forcing-function-improves-performance-ordering-restraints
    September 30, 2020 - Study Use of a computerized forcing function improves performance in ordering restraints. Citation Text: Griffey RT, Wittels K, Gilboy N, et al. Use of a computerized forcing function improves performance in ordering restraints. Ann Emerg Med. 2009;53(4):469-76. doi:10.1016/j.annemergm…

  9. Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors. | PSNet

    psnet.ahrq.gov/issue/unintentionally-retained-foreign-objects-descriptive-study-308-sentinel-events-and
    March 20, 2019 - Study Emerging Classic Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors. Citation Text: Steelman VM, Shaw C, Shine L, et al. Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentine…

  10. Reducing errors through discharge medication reconciliation by pharmacy services. | PSNet

    psnet.ahrq.gov/issue/reducing-errors-through-discharge-medication-reconciliation-pharmacy-services
    October 20, 2021 - Study Reducing errors through discharge medication reconciliation by pharmacy services. Citation Text: Bishop MA, Cohen BA, Billings LK, et al. Reducing errors through discharge medication reconciliation by pharmacy services.  Am J Health Syst Pharm. 2015;72(17 Suppl 2):S120-6. doi:10.21…

  11. Fractures of the fingers missed or misdiagnosed on poorly positioned or poorly taken radiographs: a retrospective study. | PSNet

    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…

  12. The ins and outs of change of shift handoffs between nurses: a communication challenge. | PSNet

    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…

  13. Medication safety program reduces adverse drug events in a community hospital. | PSNet

    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. Copy Citation Format:…

  14. Pharmacist work stress and learning from quality related events. | PSNet

    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. Copy Citation Fo…

  15. Clinical scenarios: enhancing the skill set of the nurse as a vigilant guardian. | PSNet

    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…

  16. Acceptance of recommendations by inpatient pharmacy case managers: unintended consequences of hospitalist and specialist care. | PSNet

    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…

  17. A randomized controlled trial on the effect of a double check on the detection of medication errors. | PSNet

    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):…

  18. Use of specific indicators to detect warfarin-related adverse events.   | PSNet

    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. Copy Cita…

  19. Exploring varieties of knowledge in safe work practices—an ethnographic study of surgical teams. | PSNet

    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…

  20. Risk of adverse drug events by patient destination after hospital discharge. | PSNet

    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. Copy Citation Format: …
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