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9821. During the pandemic, aspire to identify and prevent medication errors and to avoid blaming attitudes. | PSNet
      psnet.ahrq.gov/issue/during-pandemic-aspire-identify-and-prevent-medication-errors-and-avoid-blaming-attitudes
      September 07, 2022 - Newspaper/Magazine Article During the pandemic, aspire to identify and prevent medication errors and to avoid blaming attitudes. Citation Text: During the pandemic, aspire to identify and prevent medication errors and to avoid blaming attitudes. ISMP Medication Safety Alert! Acute care e…

9822. What is patient safety culture? A review of the literature. | PSNet
      psnet.ahrq.gov/issue/what-patient-safety-culture-review-literature
      July 19, 2023 - Review What is patient safety culture? A review of the literature. Citation Text: Sammer CE, Lykens K, Singh KP, et al. What is patient safety culture? A review of the literature. J Nurs Scholarsh. 2010;42(2):156-65. doi:10.1111/j.1547-5069.2009.01330.x. Copy Citation Format: …

9823. A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care. | PSNet
      psnet.ahrq.gov/issue/new-tool-give-hospitalists-feedback-improve-interprofessional-teamwork-and-advance-patient
      February 10, 2015 - Commentary A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care. Citation Text: Chesluk BJ, Bernabeo E, Hess B, et al. A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care. Health Aff…

9824. What if?: Transforming Diagnostic Research by Leveraging a Diagnostic Process Map to Engage Patients in Learning from Errors. | PSNet
      psnet.ahrq.gov/issue/what-if-transforming-diagnostic-research-leveraging-diagnostic-process-map-engage-patients
      October 27, 2021 - Book/Report What if?: Transforming Diagnostic Research by Leveraging a Diagnostic Process Map to Engage Patients in Learning from Errors. Citation Text: Sheridan S, Merryweather P, Rusz D, et al. What If?: Transforming Diagnostic Research By Leveraging A Diagnostic Process Map To Engage …

9825. American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards. | PSNet
      psnet.ahrq.gov/issue/american-society-clinical-oncologyoncology-nursing-society-chemotherapy-administration-safety
      October 19, 2022 - Commentary American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards. Citation Text: Jacobson J, Polovich M, McNiff KK, et al. American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards. …

9826. Preventing Falls and Injury While in the Hospital (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/action-fall-prevention-ed-tool.pdf
      June 16, 2021 - Preventing Falls and Injury While in the Hospital Preventing Falls and Injury While in the Hospital You have one or more health conditions that make it likely that you may either fall or become injured if you fall. Knowing that you are more likely to fall, we want to work with you to prevent you from fall…

9827. Use of a surgical safety checklist to improve team communication. | PSNet
      psnet.ahrq.gov/issue/use-surgical-safety-checklist-improve-team-communication
      August 08, 2018 - Commentary Use of a surgical safety checklist to improve team communication. Citation Text: Cabral RA, Eggenberger T, Keller K, et al. Use of a surgical safety checklist to improve team communication. AORN J. 2016;104(3):206-216. doi:10.1016/j.aorn.2016.06.019. Copy Citation Format…

9828. Checklist: Creating a Medicine List When Patient Brings Medicines (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-checklist-meds-final508.pdf
      June 02, 2025 - Checklist: Creating a Medicine List When Patient Brings Medicines The Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Checklist: Creating a Medicine List When patient brings medicines Starting the Process � Thank the patient for bringing in his or her medicines. � Us…

9829. Improving communication with patients with limited English proficiency. | PSNet
      psnet.ahrq.gov/issue/improving-communication-patients-limited-english-proficiency
      January 06, 2018 - Commentary Improving communication with patients with limited English proficiency. Citation Text: Taira BR. Improving Communication With Patients With Limited English Proficiency. JAMA Int Med. 2018;178(5):605-606. doi:10.1001/jamainternmed.2018.0373. Copy Citation Format: …

9830. Missed diagnosis of critical congenital heart disease. | PSNet
      psnet.ahrq.gov/issue/missed-diagnosis-critical-congenital-heart-disease
      September 09, 2020 - Study Missed diagnosis of critical congenital heart disease. Citation Text: Chang R-KR, Gurvitz M, Rodriguez S. Missed diagnosis of critical congenital heart disease. Arch Pediatr Adolesc Med. 2008;162(10):969-74. doi:10.1001/archpedi.162.10.969. Copy Citation Format: DOI…

9831. Randomized Control Trial Embedded in an Electronic Health Record - 2010 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/randomized-controlled-trial-embedded-electronic-health-record/annual-summary/2010
      January 01, 2010 - Randomized Control Trial Embedded in an Electronic Health Record - 2010 Project Name Randomized Controlled Trial Embedded in an Electronic Health Record Principal Investigator Kahn, James Organization University of California, San Francisco Funding Mechanism RFA: HS…

9832. User's manual for the IOM's 'Quality Chasm' report. | PSNet
      psnet.ahrq.gov/issue/users-manual-ioms-quality-chasm-report
      August 04, 2021 - Commentary User's manual for the IOM's 'Quality Chasm' report. Citation Text: Berwick DM. A user's manual for the IOM's 'Quality Chasm' report. Health Aff (Millwood). 2002;21(3):80-90. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote…

9833. The impact of declining clinical autopsy: need for revised healthcare policy. | PSNet
      psnet.ahrq.gov/issue/impact-declining-clinical-autopsy-need-revised-healthcare-policy
      February 14, 2018 - Review The impact of declining clinical autopsy: need for revised healthcare policy. Citation Text: Xiao J, Krueger GRF, Buja M, et al. The impact of declining clinical autopsy: need for revised healthcare policy. Am J Med Sci. 2009;337(1):41-6. doi:10.1097/MAJ.0b013e318184ce2b. Copy…

9834. Health Information Technology to Support Integration of Self-Management Support in Primary Care Delivery - 2012 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/health-information-technology-support-integration-self-management-support/annual-summary/2012
      January 01, 2012 - Health Information Technology to Support Integration of Self-Management Support in Primary Care Delivery - 2012 Project Name Health Information Technology to Support Integration of Self-Management Support in Primary Care Delivery Principal Investigator Lamer, Christopher Organiza…

9835. Evaluation of frequency of paediatric oral liquid medication dosing errors by caregivers: amoxicillin and josamycin. | PSNet
      psnet.ahrq.gov/issue/evaluation-frequency-paediatric-oral-liquid-medication-dosing-errors-caregivers-amoxicillin
      May 31, 2023 - Study Evaluation of frequency of paediatric oral liquid medication dosing errors by caregivers: amoxicillin and josamycin. Citation Text: Berthe-Aucejo A, Girard D, Lorrot M, et al. Evaluation of frequency of paediatric oral liquid medication dosing errors by caregivers: amoxicillin and …

9836. Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval. | PSNet
      psnet.ahrq.gov/issue/natural-history-retained-surgical-items-supports-need-team-training-early-recognition-and
      January 18, 2013 - Study Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval. Citation Text: Stawicki P, Cook CH, Anderson HL, et al. Natural history of retained surgical items supports the need for team training, early recognition, and pr…

9837. The recurring problem of retained swabs and instruments. | PSNet
      psnet.ahrq.gov/issue/recurring-problem-retained-swabs-and-instruments
      June 19, 2019 - Review The recurring problem of retained swabs and instruments. Citation Text: Mahran MA, Toeima E, Morris EP. The recurring problem of retained swabs and instruments. Best Pract Res Clin Obstet Gynaecol. 2013;27(4):489-95. doi:10.1016/j.bpobgyn.2013.03.001. Copy Citation Format:…

9838. Label design affects medication safety in an operating room crisis: a controlled simulation study. | PSNet
      psnet.ahrq.gov/issue/label-design-affects-medication-safety-operating-room-crisis-controlled-simulation-study
      April 24, 2018 - Study Label design affects medication safety in an operating room crisis: a controlled simulation study. Citation Text: Estock JL, Murray AW, Mizah MT, et al. Label Design Affects Medication Safety in an Operating Room Crisis: A Controlled Simulation Study. J Patient Saf. 2018;14(2):101-…

9839. Self-reported adverse events in health care that cause harm: a population-based survey. | PSNet
      psnet.ahrq.gov/issue/self-reported-adverse-events-health-care-cause-harm-population-based-survey
      September 20, 2011 - Study Self-reported adverse events in health care that cause harm: a population-based survey. Citation Text: Adams RJ, Tucker G, Price K, et al. Self-reported adverse events in health care that cause harm: a population-based survey. Med J Aust. 2009;190(9):484-8. Copy Citation Fo…

9840. The top 10 list for a safe and effective sign-out. | PSNet
      psnet.ahrq.gov/issue/top-10-list-safe-and-effective-sign-out
      April 12, 2019 - Commentary The top 10 list for a safe and effective sign-out. Citation Text: Kemp CD, Bath JM, Berger J, et al. The top 10 list for a safe and effective sign-out. Arch Surg. 2008;143(10):1008-10. doi:10.1001/archsurg.143.10.1008. Copy Citation Format: DOI Google Scholar P…