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  1. A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. | PSNet

    psnet.ahrq.gov/issue/perfect-storm-averted-flawed-systems-dropped-ball-and-cognitive-biases-delay-critical
    November 30, 2022 - Commentary A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. Citation Text: Roberts TJ, Sellars MC, Sands JM, et al. A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. JCO Oncol…

  2. General practitioners' attitudes toward reporting and learning from adverse events: results from a survey. | PSNet

    psnet.ahrq.gov/issue/general-practitioners-attitudes-toward-reporting-and-learning-adverse-events-results-survey
    September 13, 2023 - Study General practitioners' attitudes toward reporting and learning from adverse events: results from a survey. Citation Text: Mikkelsen TH, Sokolowski I, Olesen F. General practitioners' attitudes toward reporting and learning from adverse events: results from a survey. Scand J Prim …

  3. 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…

  4. Mandating limits on workload, duty, and speed in radiology. | PSNet

    psnet.ahrq.gov/issue/mandating-limits-workload-duty-and-speed-radiology
    August 11, 2021 - Review Mandating limits on workload, duty, and speed in radiology. Citation Text: Alexander R, Waite S, Bruno MA, et al. Mandating limits on workload, duty, and speed in radiology. Radiology. 2022:212631. doi:10.1148/radiol.212631. Copy Citation Format: DOI Google Scholar B…

  5. Hospira issues a voluntary nationwide recall for one lot of 0.5% Bupivacaine Hydrochloride Injection, USP and one lot of 1% Lidocaine HCl Injection, USP due to mislabeling. | PSNet

    psnet.ahrq.gov/issue/hospira-issues-voluntary-nationwide-recall-one-lot-05-bupivacaine-hydrochloride-injection-usp
    June 20, 2018 - Press Release/Announcement Hospira issues a voluntary nationwide recall for one lot of 0.5% Bupivacaine Hydrochloride Injection, USP and one lot of 1% Lidocaine HCl Injection, USP due to mislabeling. Citation Text: Hospira issues a voluntary nationwide recall for one lot of 0.5% Bupivaca…

  6. Training induces cognitive bias: the case of a simulation-based emergency airway curriculum. | PSNet

    psnet.ahrq.gov/issue/training-induces-cognitive-bias-case-simulation-based-emergency-airway-curriculum
    May 18, 2022 - Study Training induces cognitive bias: the case of a simulation-based emergency airway curriculum. Citation Text: Park C, Stojiljkovic L, Milicic B, et al. Training induces cognitive bias: the case of a simulation-based emergency airway curriculum. Simul Healthc. 2014;9(2):85-93. doi:10.…

  7. Safety in the academic medical center: transforming challenges into ingredients for improvement. | PSNet

    psnet.ahrq.gov/issue/safety-academic-medical-center-transforming-challenges-ingredients-improvement
    February 17, 2011 - Review Safety in the academic medical center: transforming challenges into ingredients for improvement. Citation Text: Blumenthal D, Ferris T. Safety in the academic medical center: transforming challenges into ingredients for improvement. Acad Med. 2006;81(9):817-22. Copy Citation …

  8. Using the internet to deliver education on drug safety. | PSNet

    psnet.ahrq.gov/issue/using-internet-deliver-education-drug-safety
    March 23, 2011 - Study Using the internet to deliver education on drug safety. Citation Text: Franklin B, O'Grady K, Parr J, et al. Using the internet to deliver education on drug safety. Qual Saf Health Care. 2006;15(5):329-33. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X…

  9. Comparison of medication safety systems in critical access hospitals: combined analysis of two studies. | PSNet

    psnet.ahrq.gov/issue/comparison-medication-safety-systems-critical-access-hospitals-combined-analysis-two-studies
    September 28, 2016 - Study Comparison of medication safety systems in critical access hospitals: combined analysis of two studies. Citation Text: Cochran GL, Barrett RS, Horn SD. Comparison of medication safety systems in critical access hospitals: Combined analysis of two studies. Am J Health Syst Pharm. 20…

  10. Errors prevented by and associated with bar-code medication administration systems. | PSNet

    psnet.ahrq.gov/issue/errors-prevented-and-associated-bar-code-medication-administration-systems
    October 16, 2019 - Study Errors prevented by and associated with bar-code medication administration systems. Citation Text: Cochran GL, Jones KJ, Brockman J, et al. Errors prevented by and associated with bar-code medication administration systems. Jt Comm J Qual Patient Saf. 2007;33(5):293-301, 245. Cop…

  11. Rework and workarounds in nurse medication administration process: implications for work processes and patient safety. | PSNet

    psnet.ahrq.gov/issue/rework-and-workarounds-nurse-medication-administration-process-implications-work-processes
    July 31, 2008 - Study Rework and workarounds in nurse medication administration process: implications for work processes and patient safety. Citation Text: Halbesleben JRB, Savage GT, Wakefield DS, et al. Rework and workarounds in nurse medication administration process: implications for work processes…

  12. Identification of adverse events in ground transport emergency medical services. | PSNet

    psnet.ahrq.gov/issue/identification-adverse-events-ground-transport-emergency-medical-services
    August 26, 2020 - Study Identification of adverse events in ground transport emergency medical services. Citation Text: Patterson PD, Weaver MD, Abebe K, et al. Identification of adverse events in ground transport emergency medical services. Am J Med Qual. 2011;27(2):139-146. doi:10.1177/106286061141551…

  13. Track 5: Achieving and Sustaining Improvements | Digital Healthcare Research

    digital.ahrq.gov/track-5-achieving-and-sustaining-improvements
    January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…

  14. Identifying the latent failures underpinning medication administration errors: an exploratory study. | PSNet

    psnet.ahrq.gov/issue/identifying-latent-failures-underpinning-medication-administration-errors-exploratory-study
    December 21, 2016 - Study Identifying the latent failures underpinning medication administration errors: an exploratory study. Citation Text: Lawton R, Carruthers S, Gardner P, et al. Identifying the latent failures underpinning medication administration errors: an exploratory study. Health Serv Res. 2012…

  15. What 'just culture' doesn't understand about just punishment. | PSNet

    psnet.ahrq.gov/issue/what-just-culture-doesnt-understand-about-just-punishment
    December 30, 2014 - Commentary What 'just culture' doesn't understand about just punishment. Citation Text: Reis-Dennis S. What 'Just Culture' doesn't understand about just punishment. J Med Ethics. 2018;44(11):739-742. doi:10.1136/medethics-2018-104911. Copy Citation Format: DOI Google Schola…

  16. Teaching medical students about medical errors and patient safety: evaluation of a required curriculum. | PSNet

    psnet.ahrq.gov/issue/teaching-medical-students-about-medical-errors-and-patient-safety-evaluation-required
    June 08, 2022 - Study Teaching medical students about medical errors and patient safety: evaluation of a required curriculum. Citation Text: Halbach JL, Sullivan LL. Teaching medical students about medical errors and patient safety: evaluation of a required curriculum. Acad Med. 2005;80(6):600-6. Co…

  17. Preventing medication errors in community pharmacy: frequency and seriousness of medication errors. | PSNet

    psnet.ahrq.gov/issue/preventing-medication-errors-community-pharmacy-frequency-and-seriousness-medication-errors
    June 14, 2011 - Study Preventing medication errors in community pharmacy: frequency and seriousness of medication errors. Citation Text: Knudsen P, Herborg H, Mortensen AR, et al. Preventing medication errors in community pharmacy: frequency and seriousness of medication errors. Qual Saf Health Care. …

  18. Patient safety climate in primary care: age matters. | PSNet

    psnet.ahrq.gov/issue/patient-safety-climate-primary-care-age-matters
    June 11, 2010 - Study Patient safety climate in primary care: age matters. Citation Text: Holden LM, Watts DD, Walker PH. Patient safety climate in primary care: age matters. J Patient Saf. 2009;5(1):23-28. doi:10.1097/PTS.0b013e318199d4bf. Copy Citation Format: DOI Google Scholar PubMed…

  19. Improving adverse drug event reporting by healthcare professionals. | PSNet

    psnet.ahrq.gov/issue/improving-adverse-drug-event-reporting-healthcare-professionals
    April 12, 2019 - Review Improving adverse drug event reporting by healthcare professionals. Citation Text: Shalviri G, Mohebbi N, Mirbaha F, et al. Improving adverse drug event reporting by healthcare professionals. Cochrane Database Syst Rev. 2024;2024(10):CD012594. doi:10.1002/14651858.cd012594.pub2. …

  20. The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives. | PSNet

    psnet.ahrq.gov/issue/henry-ford-health-system-no-harm-campaign-comprehensive-model-reduce-harm-and-save-lives
    May 11, 2019 - Commentary The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives. Citation Text: Conway WA, Hawkins S, Jordan J, et al. 2011 John M. Eisenberg Patient Safety and Quality Awards. The Henry Ford Health System No Harm Campaign: a comprehensive mo…
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