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9801. Application of lean thinking to health care: issues and observations. | PSNet
      psnet.ahrq.gov/issue/application-lean-thinking-health-care-issues-and-observations
      May 28, 2015 - Commentary Application of lean thinking to health care: issues and observations. Citation Text: Joosten T, Bongers I, Janssen R. Application of lean thinking to health care: issues and observations. International Journal for Quality in Health Care. 2009;21(5). doi:10.1093/intqhc/mzp036…

9802. The second victim: a review. | PSNet
      psnet.ahrq.gov/issue/second-victim-review
      June 26, 2019 - Review The second victim: a review. Citation Text: Coughlan B, Powell D, Higgins MF. The Second Victim: a Review. Eur J Obstet Gynecol Reprod Biol. 2017;213:11-16. doi:10.1016/j.ejogrb.2017.04.002. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNot…

9803. The anatomy of health care team training and the state of practice: a critical review. | PSNet
      psnet.ahrq.gov/issue/anatomy-health-care-team-training-and-state-practice-critical-review
      March 21, 2017 - Review The anatomy of health care team training and the state of practice: a critical review. Citation Text: Weaver SJ, Lyons R, DiazGranados D, et al. The anatomy of health care team training and the state of practice: a critical review. Acad Med. 2010;85(11):1746-60. doi:10.1097/ACM.0b…

9804. Unmet Needs: Teaching Physicians to Provide Safe Patient Care. | PSNet
      psnet.ahrq.gov/issue/unmet-needs-teaching-physicians-provide-safe-patient-care
      November 07, 2012 - Book/Report Classic Unmet Needs: Teaching Physicians to Provide Safe Patient Care. Citation Text: Unmet Needs: Teaching Physicians to Provide Safe Patient Care. Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; March 2010. Copy Cita…

9805. How communication "failed" or "saved the day": counterfactual accounts of medical errors. | PSNet
      psnet.ahrq.gov/issue/how-communication-failed-or-saved-day-counterfactual-accounts-medical-errors
      September 21, 2022 - Study How communication "failed" or "saved the day": counterfactual accounts of medical errors. Citation Text: Street RL, Petrocelli JV, Amroze A, et al. How Communication “Failed” or “Saved the Day”: Counterfactual Accounts of Medical Errors. J Patient Exp. 2020;7(6):1247-1254. doi:10.1…

9806. Nursing and physician attire as possible source of nosocomial infections. | PSNet
      psnet.ahrq.gov/issue/nursing-and-physician-attire-possible-source-nosocomial-infections
      July 01, 2016 - Study Nursing and physician attire as possible source of nosocomial infections. Citation Text: Wiener-Well Y, Galuty M, Rudensky B, et al. Nursing and physician attire as possible source of nosocomial infections. Am J Infect Control. 2011;39(7):555-9. doi:10.1016/j.ajic.2010.12.016. …

9807. The effect of drug concentration expression on epinephrine dosing errors: a randomized trial. | PSNet
      psnet.ahrq.gov/issue/effect-drug-concentration-expression-epinephrine-dosing-errors-randomized-trial
      August 27, 2008 - Study The effect of drug concentration expression on epinephrine dosing errors: a randomized trial. Citation Text: Wheeler DW, Carter JJ, Murray LJ, et al. The effect of drug concentration expression on epinephrine dosing errors: a randomized trial. Ann Intern Med. 2008;148(1):11-4. …

9808. Intrathecal chemotherapy: potential for medication error. | PSNet
      psnet.ahrq.gov/issue/intrathecal-chemotherapy-potential-medication-error
      February 23, 2015 - Review Intrathecal chemotherapy: potential for medication error. Citation Text: Gilbar PJ. Intrathecal chemotherapy: potential for medication error. Cancer Nurs. 2014;37(4):299-309. doi:10.1097/NCC.0000000000000108. Copy Citation Format: DOI Google Scholar PubMed BibTeX End…

9809. Rx for medication errors. | PSNet
      psnet.ahrq.gov/issue/rx-medication-errors
      July 19, 2023 - Newspaper/Magazine Article Rx for medication errors. Citation Text: Friedley NJC. Rx for medication errors. A patient medication safety plan can help prevent the cascade of devastating and preventable complications from adverse drug events. Medical economics. 2008;85(20):34-8. Copy …

9810. e3iVR: Conference on Ethics in Investigational and Interventional Uses of Immersive VR | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/e3ivr-conference-ethics-investigational-and-interventional-uses-immersive-vr
      January 01, 2023 - e3iVR: Conference on Ethics in Investigational and Interventional Uses of Immersive VR Project Final Report ( PDF , 844.27 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessa…

9811. Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error. | PSNet
      psnet.ahrq.gov/issue/position-statement-criminalization-medical-error-and-call-action-prevent-patient-harm-error
      December 02, 2020 - Organizational Policy/Guidelines Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error. Citation Text: Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error. Cooper J, Thomas B…

9812. Cognitive bias in clinical medicine. | PSNet
      psnet.ahrq.gov/issue/cognitive-bias-clinical-medicine
      February 20, 2019 - Commentary Classic Cognitive bias in clinical medicine. Citation Text: O'Sullivan ED, Schofield SJ. Cognitive bias in clinical medicine. J R Coll Physicians Edinb. 2018;48(3):225-232. doi:10.4997/JRCPE.2018.306. Copy Citation Format: DOI Google Sch…

9813. When health care moves online, many patients are left behind. | PSNet
      psnet.ahrq.gov/issue/when-health-care-moves-online-many-patients-are-left-behind
      August 19, 2020 - Newspaper/Magazine Article When health care moves online, many patients are left behind. Citation Text: Renault M. When health care moves online, many patients are left behind. Wired Online. 2020;(June 8, 2020). Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…

9814. Physicians and electronic health records: a statewide survey. | PSNet
      psnet.ahrq.gov/issue/physicians-and-electronic-health-records-statewide-survey
      December 31, 2014 - Study Physicians and electronic health records: a statewide survey. Citation Text: Simon SR, Kaushal R, Cleary PD, et al. Physicians and electronic health records: a statewide survey. Arch Intern Med. 2007;167(5):507-12. Copy Citation Format: Google Scholar PubMed BibTeX …

9815. Health information technology is a vehicle, not a destination: a conversation with David J. Brailer. | PSNet
      psnet.ahrq.gov/issue/health-information-technology-vehicle-not-destination-conversation-david-j-brailer
      March 19, 2019 - Commentary Health information technology is a vehicle, not a destination: a conversation with David J. Brailer. Citation Text: Brailer DJ. Health information technology is a vehicle, not a destination: a conversation with David J. Brailer. Interview by Arnold Milstein. Health Aff (Mill…

9816. National Nursing Home COVID Action Network. | PSNet
      psnet.ahrq.gov/issue/national-nursing-home-covid-action-network
      October 23, 2019 - Multi-use Website National Nursing Home COVID Action Network. Citation Text: National Nursing Home COVID Action Network. Rockville, MD: Agency for Healthcare Research and Quality; September 2020. Copy Citation Save Save to your library Print Download P…

9817. Why talking is not cheap: adverse events and informal communication. | PSNet
      psnet.ahrq.gov/issue/why-talking-not-cheap-adverse-events-and-informal-communication
      September 24, 2014 - Commentary Why talking is not cheap: adverse events and informal communication. Citation Text: Montgomery A, Lainidi O, Georganta K. Why talking is not cheap: adverse events and informal communication. Healthcare (Basel). 2024;12(6):635. doi:10.3390/healthcare12060635. Copy Citation …

9818. The eNOTSS platform for surgeons’ nontechnical skills performance improvement. | PSNet
      psnet.ahrq.gov/issue/enotss-platform-surgeons-nontechnical-skills-performance-improvement
      July 01, 2017 - Commentary The eNOTSS platform for surgeons’ nontechnical skills performance improvement. Citation Text: Pradarelli JC, Yule S, Smink DS. The eNOTSS Platform for Surgeons’ Nontechnical Skills Performance Improvement. JAMA Surg. 2020;155(5):438-439. doi:10.1001/jamasurg.2019.5880. Copy …

9819. The inevitability of physician burnout: implications for interventions. | PSNet
      psnet.ahrq.gov/issue/inevitability-physician-burnout-implications-interventions
      April 17, 2024 - Commentary The inevitability of physician burnout: implications for interventions. Citation Text: Montgomery A. The inevitability of physician burnout: Implications for interventions. Burn Res. 2014;1(1). doi:10.1016/j.burn.2014.04.002. Copy Citation Format: DOI Google Scho…

9820. Detection and prevention of medication errors using real-time bedside nurse charting. | PSNet
      psnet.ahrq.gov/issue/detection-and-prevention-medication-errors-using-real-time-bedside-nurse-charting
      September 27, 2017 - Study Detection and prevention of medication errors using real-time bedside nurse charting. Citation Text: Nelson NC, Evans RS, Samore MH, et al. Detection and Prevention of Medication Errors Using Real-Time Bedside Nurse Charting. Journal of the American Medical Informatics Associatio…