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psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - SPOTLIGHT CASE
Medication Reconciliation: Whose Job Is It?
Citation Text:
Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - Right Patient, Wrong Sample
Citation Text:
Astion ML. Right Patient, Wrong Sample. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/33740/psn-pdf
November 01, 2012 - RW: Have we entered a kind of death spiral phase where nobody knows how to either do a high-quality
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psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - Right Patient, Wrong Sample
December 1, 2006
Astion ML. Right Patient, Wrong Sample. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample
The Case
A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. On
the morning of surgery, the patien…
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psnet.ahrq.gov/node/60172/psn-pdf
March 01, 2021 - During the upfront planning phase, roughly 8 to 10 staff
participated in the core patient identification
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psnet.ahrq.gov/issue/nearing-zeroreducing-grade-c-medication-errors
October 05, 2022 - Commentary
Nearing zero...reducing grade C medication errors.
Citation Text:
Cockerham J, Figueroa-Altmann A, Foxen C, et al. Nearing zero..reducing grade C medication errors. Nurs Manage. 2014;45(7):26-31. doi:10.1097/01.NUMA.0000451033.38845.d3.
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psnet.ahrq.gov/issue/pediatric-medication-administration-errors-and-workflow-following-implementation-bar-code
July 02, 2019 - Study
Pediatric medication administration errors and workflow following implementation of a bar code medication administration system.
Citation Text:
Hardmeier A, Tsourounis C, Moore M, et al. Pediatric medication administration errors and workflow following implementation of a bar code …
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psnet.ahrq.gov/issue/dual-process-cognitive-interventions-enhance-diagnostic-reasoning-systematic-review
March 20, 2019 - Review
Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review.
Citation Text:
Lambe KA, O'Reilly G, Kelly BD, et al. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. BMJ Qual Saf. 2016;25(10):808-820. doi:10.113…
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psnet.ahrq.gov/issue/momentary-interruptions-can-derail-train-thought
May 18, 2022 - Study
Momentary interruptions can derail the train of thought.
Citation Text:
Altmann EM, Trafton G, Hambrick DZ. Momentary interruptions can derail the train of thought. J Exp Psychol Gen. 2014;143(1):215-26. doi:10.1037/a0030986.
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psnet.ahrq.gov/issue/relationship-between-high-fidelity-simulation-and-patient-safety-prelicensure-nursing
October 19, 2022 - Review
Relationship between high-fidelity simulation and patient safety in prelicensure nursing education: a comprehensive review.
Citation Text:
Blum CA, Parcells DA. Relationship between high-fidelity simulation and patient safety in prelicensure nursing education: a comprehensive re…
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psnet.ahrq.gov/issue/morning-briefing-setting-stage-clinically-and-operationally-good-day
June 28, 2010 - Tools/Toolkit
A morning briefing: setting the stage for a clinically and operationally good day.
Citation Text:
Thompson DA, Holzmueller CG, Hunt D, et al. A morning briefing: setting the stage for a clinically and operationally good day. Jt Comm J Qual Patient Saf. 2005;31(8):476-9.
C…
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psnet.ahrq.gov/issue/results-survey-pediatric-medication-safety-part-1-and-part-2
November 16, 2015 - Newspaper/Magazine Article
Results of survey on pediatric medication safety—part 1 and part 2.
Citation Text:
Results of survey on pediatric medication safety—part 1 and part 2. ISMP Medication Safety Alert! Acute Care Edition. June 4, 2015;20:1-6. July 2, 2015;20:1-5.
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psnet.ahrq.gov/issue/misdiagnosis-analysis-based-case-record-review-proposals-aimed-improve-diagnostic-processes
November 12, 2014 - Study
Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes.
Citation Text:
Neale G, Hogan H, Sevdalis N. Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes. Clin Med (Lond). 2011;11(…
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psnet.ahrq.gov/issue/medication-related-clinical-decision-support-computerized-provider-order-entry-systems-review
March 11, 2011 - Review
Medication-related clinical decision support in computerized provider order entry systems: a review.
Citation Text:
Kuperman GJ, Bobb A, Payne TH, et al. Medication-related clinical decision support in computerized provider order entry systems: a review. J Am Med Inform Assoc. 2…
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psnet.ahrq.gov/issue/team-checkup-tool-evaluating-qi-team-activities-and-giving-feedback-senior-leaders
November 27, 2012 - Commentary
The Team Checkup Tool: evaluating QI team activities and giving feedback to senior leaders.
Citation Text:
Lubomski LH, Marsteller JA, Hsu Y-J, et al. The team checkup tool: evaluating QI team activities and giving feedback to senior leaders. Jt Comm J Qual Patient Saf. 2008;3…
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psnet.ahrq.gov/issue/time-trends-pulmonary-embolism-united-states-evidence-overdiagnosis
February 18, 2011 - Study
Time trends in pulmonary embolism in the United States: evidence of overdiagnosis.
Citation Text:
Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med. 2011;171(9):831-7. doi:10.1001/archinternmed.20…
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psnet.ahrq.gov/issue/impact-unit-based-patient-safety-officer
September 19, 2012 - Study
Impact of the unit-based patient safety officer.
Citation Text:
Nedved P, Chaudhry R, Pilipczuk D, et al. Impact of the unit-based patient safety officer. J Nurs Adm. 2012;42(9):431-434. doi:10.1097/NNA.0b013e318266810e.
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psnet.ahrq.gov/issue/personalised-performance-feedback-reduces-narcotic-prescription-errors-nicu
July 13, 2010 - Study
Personalised performance feedback reduces narcotic prescription errors in a NICU.
Citation Text:
Sullivan KM, Suh S, Monk H, et al. Personalised performance feedback reduces narcotic prescription errors in a NICU. BMJ Qual Saf. 2013;22(3):256-62. doi:10.1136/bmjqs-2012-001089.
C…
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psnet.ahrq.gov/issue/creation-and-impact-dedicated-section-quality-and-patient-safety-clinical-academic-department
May 28, 2008 - Commentary
The creation and impact of a dedicated section on quality and patient safety in a clinical academic department.
Citation Text:
Boudreaux AM, Vetter TR. The Creation and Impact of a Dedicated Section on Quality and Patient Safety in a Clinical Academic Department. Academic Medi…
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psnet.ahrq.gov/issue/hospital-ethical-climate-and-teamwork-acute-care-moderating-role-leaders
October 15, 2016 - Study
Hospital ethical climate and teamwork in acute care: the moderating role of leaders.
Citation Text:
Rathert C, Fleming DA. Hospital ethical climate and teamwork in acute care: the moderating role of leaders. Health Care Manag Rev. 2008;33(4):323-331. doi:10.1097/01.HCM.0000318769.7…