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FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that accidental exposure to used patches can cause death. | PSNet

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August 05, 2020 - Press Release/Announcement FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that accidental exposure to used patches can cause death. Citation Text: FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that…

2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, including standards for pediatric oncology. | PSNet

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February 15, 2023 - Commentary 2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, including standards for pediatric oncology. Citation Text: Belderson KM, Billett AL. Chemotherapy safety standards: A pediatric perspective. J Oncol Pract.…

Leadership behaviors, attitudes and characteristics to support a culture of safety. | PSNet

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August 03, 2022 - Study Leadership behaviors, attitudes and characteristics to support a culture of safety. Citation Text: Montminy SL. Leadership behaviors, attitudes and characteristics to support a culture of safety. J Healthc Risk Manag. 2022;42(2):31-38. doi:10.1002/jhrm.21521. Copy Citation Fo…

Instituting a culture of professionalism: the establishment of a Center for Professionalism and Peer Support. | PSNet

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March 03, 2011 - Commentary Instituting a culture of professionalism: the establishment of a Center for Professionalism and Peer Support. Citation Text: Shapiro J, Whittemore A, Tsen LC. Instituting a culture of professionalism: the establishment of a center for professionalism and peer support. Jt Comm …

Using incident reporting to improve patient safety: a conceptual model. | PSNet

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June 29, 2009 - Commentary Using incident reporting to improve patient safety: a conceptual model. Citation Text: Pronovost PJ, Holzmueller CG, Young J, et al. Using Incident Reporting to Improve Patient Safety. J Patient Saf. 2008;3(1). doi:10.1097/pts.0b013e318030ca05. Copy Citation Format: …

Relationship between quality of care and negligence litigation in nursing homes. | PSNet

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September 07, 2011 - Study Relationship between quality of care and negligence litigation in nursing homes. Citation Text: Studdert DM, Spittal MJ, Mello MM, et al. Relationship between quality of care and negligence litigation in nursing homes. N Engl J Med. 2011;364(13):1243-1250. doi:10.1056/nejmsa100933…

Exploring emergency physician–hospitalist handoff interactions: development of the Handoff Communication Assessment. | PSNet

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December 19, 2011 - Study Exploring emergency physician–hospitalist handoff interactions: development of the Handoff Communication Assessment. Citation Text: Apker J, Mallak LA, Applegate B, et al. Exploring emergency physician-hospitalist handoff interactions: development of the Handoff Communication Ass…

Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. | PSNet

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February 03, 2011 - Study Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. Citation Text: Parnes B, Fernald D, Quintela J, et al. Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. Qual Saf Health Care. 2007;16(1):12-6. Copy Citation …

What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings. | PSNet

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July 27, 2011 - Study What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings. Citation Text: Allard J, Bleakley A. What would you ideally do if there were no targets? An ethnographic study of the unintended…

A team disclosure of error educational activity: objective outcomes. | PSNet

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January 31, 2018 - Study A team disclosure of error educational activity: objective outcomes. Citation Text: Krumwiede KH, Wagner JM, Kirk LM, et al. A Team Disclosure of Error Educational Activity: Objective Outcomes. J Am Geriatr Soc. 2019;67(6):1273-1277. doi:10.1111/jgs.15883. Copy Citation Forma…

Opioids and falls risk in older adults: a narrative review. | PSNet

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January 12, 2022 - Review Opioids and falls risk in older adults: a narrative review. Citation Text: Virnes R-E, Tiihonen M, Karttunen N, et al. Opioids and falls risk in older adults: a narrative review. Drugs Aging. 2022;39(3):199-207. doi:10.1007/s40266-022-00929-y. Copy Citation Format: D…

Medication errors with pediatric liquid acetaminophen after standardization of concentration and packaging improvements. | PSNet

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May 19, 2021 - Study Medication errors with pediatric liquid acetaminophen after standardization of concentration and packaging improvements. Citation Text: Brass EP, Reynolds KM, Burnham RI, et al. Medication Errors With Pediatric Liquid Acetaminophen After Standardization of Concentration and Packagi…

Economic evaluation of the impact of medication errors reported by US clinical pharmacists. | PSNet

psnet.ahrq.gov/issue/economic-evaluation-impact-medication-errors-reported-us-clinical-pharmacists

February 02, 2011 - Study Economic evaluation of the impact of medication errors reported by US clinical pharmacists. Citation Text: Samp JC, Touchette DR, Marinac JS, et al. Economic evaluation of the impact of medication errors reported by U.S. clinical pharmacists. Pharmacotherapy. 2014;34(4):350-7. doi:…

Implementation and evaluation of a laboratory safety process improvement toolkit. | PSNet

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July 12, 2010 - Study Implementation and evaluation of a laboratory safety process improvement toolkit. Citation Text: Kwan BM, Fernald D, Ferrarone P, et al. Implementation and Evaluation of a Laboratory Safety Process Improvement Toolkit. J Am Board Fam Med. 2019;32(2):136-145. doi:10.3122/jabfm.2019.…

Targeting improvements in patient safety at a large academic center: an institutional handoff curriculum for graduate medical education. | PSNet

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August 03, 2017 - Commentary Targeting improvements in patient safety at a large academic center: an institutional handoff curriculum for graduate medical education. Citation Text: Allen S, Caton C, Cluver J, et al. Targeting improvements in patient safety at a large academic center: an institutional hand…

Discrepancies between clinical diagnoses and autopsy findings in critically ill children: a prospective study. | PSNet

psnet.ahrq.gov/issue/discrepancies-between-clinical-diagnoses-and-autopsy-findings-critically-ill-children

January 12, 2022 - Study Discrepancies between clinical diagnoses and autopsy findings in critically ill children: a prospective study. Citation Text: Carlotti APCP, Bachette LG, Carmona F, et al. Discrepancies Between Clinical Diagnoses and Autopsy Findings in Critically Ill Children: A Prospective Study.…

Facility-level variation in potentially inappropriate prescribing for older veterans. | PSNet

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February 17, 2017 - Study Facility-level variation in potentially inappropriate prescribing for older veterans. Citation Text: Gellad WF, Good CB, Amuan ME, et al. Facility-level variation in potentially inappropriate prescribing for older veterans. J Am Geriatr Soc. 2012;60(7):1222-9. doi:10.1111/j.1532-5…

Closing the gap and raising the bar: assessing board competency in quality and safety. | PSNet

psnet.ahrq.gov/issue/closing-gap-and-raising-bar-assessing-board-competency-quality-and-safety

July 20, 2022 - Study Closing the gap and raising the bar: assessing board competency in quality and safety. Citation Text: McGaffigan PA, Ullem BD, Gandhi TK. Closing the Gap and Raising the Bar: Assessing Board Competency in Quality and Safety. Jt Comm J Qual Patient Saf. 2017;43(6):267-274. doi:10.10…

Comparative, cross-sectional study of the format, content and timing of medication safety letters issued in Canada, the USA and the UK. | PSNet

psnet.ahrq.gov/issue/comparative-cross-sectional-study-format-content-and-timing-medication-safety-letters-issued

March 21, 2012 - Study Comparative, cross-sectional study of the format, content and timing of medication safety letters issued in Canada, the USA and the UK. Citation Text: Bjerre LM, Parlow S, de Launay D, et al. Comparative, cross-sectional study of the format, content and timing of medication safety …

Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents. | PSNet

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August 04, 2021 - Study Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents. Citation Text: Davies EC, Green CF, Mottram DR, et al. Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents. Br J Clin Pharmacol. 2010;70(1):102-8. doi:10.1111/…

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