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psnet.ahrq.gov/issue/surrogate-decision-makers-perspectives-preventable-breakdowns-care-among-critically-ill
June 07, 2016 - Study
Surrogate decision makers' perspectives on preventable breakdowns in care among critically ill patients: a qualitative study.
Citation Text:
Fisher K, Ahmad S, Jackson M, et al. Surrogate decision makers' perspectives on preventable breakdowns in care among critically ill patients:…
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psnet.ahrq.gov/issue/move-toward-full-use-metric-dosing-eliminate-dosage-cups-measure-liquids-fluid-drams-use-cups
April 01, 2015 - Press Release/Announcement
Move toward full use of metric dosing: eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL.
Citation Text:
Move toward full use of metric dosing: eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL…
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psnet.ahrq.gov/issue/toward-understanding-errors-inpatient-psychiatry-qualitative-inquiry
December 21, 2018 - Study
Toward understanding errors in inpatient psychiatry: a qualitative inquiry.
Citation Text:
Cullen SW, Nath SB, Marcus SC. Toward understanding errors in inpatient psychiatry: a qualitative inquiry. Psychiatr Q. 2010;81(3):197-205. doi:10.1007/s11126-010-9129-z.
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psnet.ahrq.gov/issue/problem-my-five-moments-hand-hygiene
September 09, 2020 - Commentary
The problem with 'My Five Moments for Hand Hygiene'.
Citation Text:
Gould D, Purssell E, Jeanes A, et al. The problem with ‘My Five Moments for Hand Hygiene’. BMJ Qual Saf. 2022;31(4):322-326. doi:10.1136/bmjqs-2020-011911.
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psnet.ahrq.gov/issue/interventions-improve-hand-hygiene-compliance-patient-care
September 09, 2020 - Review
Interventions to improve hand hygiene compliance in patient care.
Citation Text:
Gould DJ, Moralejo D, Drey N, et al. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev. 2017;9(9):CD005186. doi:10.1002/14651858.cd005186.pub4.
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psnet.ahrq.gov/issue/peer-review-comments-augment-diagnostic-error-characterization-and-departmental-quality
September 02, 2020 - Study
Peer review comments augment diagnostic error characterization and departmental quality assurance: 1-year experience from a children's hospital.
Citation Text:
Iyer RS, Swanson JO, Otto RK, et al. Peer review comments augment diagnostic error characterization and departmental quali…
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psnet.ahrq.gov/issue/epidemiology-adverse-events-air-medical-transport
July 03, 2014 - Study
Epidemiology of adverse events in air medical transport.
Citation Text:
MacDonald RD, Banks BA, Morrison M. Epidemiology of adverse events in air medical transport. Acad Emerg Med. 2008;15(10):923-931. doi:10.1111/j.1553-2712.2008.00241.x.
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psnet.ahrq.gov/issue/interruptions-emergency-department-work-observational-and-interview-study
September 29, 2021 - Study
Interruptions in emergency department work: an observational and interview study.
Citation Text:
Berg LM, Källberg A-S, Göransson KE, et al. Interruptions in emergency department work: an observational and interview study. BMJ Qual Saf. 2013;22(8):656-63. doi:10.1136/bmjqs-2013-001…
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psnet.ahrq.gov/issue/matching-identifiers-electronic-health-records-implications-duplicate-records-and-patient
October 13, 2015 - Study
Matching identifiers in electronic health records: implications for duplicate records and patient safety.
Citation Text:
McCoy AB, Wright A, Kahn MG, et al. Matching identifiers in electronic health records: implications for duplicate records and patient safety. BMJ Qual Saf. 20…
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psnet.ahrq.gov/issue/diet-order-entry-registered-dietitians-results-reduction-error-rates-and-time-delays-compared
September 23, 2020 - Study
Diet order entry by registered dietitians results in a reduction in error rates and time delays compared with other health professionals.
Citation Text:
Imfeld K, Keith M, Stoyanoff L, et al. Diet order entry by registered dietitians results in a reduction in error rates and time …
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psnet.ahrq.gov/issue/surgical-intraoperative-handoff-initiative-standardizing-operating-room-communication-using
October 04, 2023 - Study
Surgical intraoperative handoff initiative: standardizing operating room communication using SHRIMPS.
Citation Text:
Stephens WA, Anderson MJ, Levy BE, et al. Surgical intraoperative handoff initiative: standardizing operating room communication using SHRIMPS. J Am Coll Surg. 2024;…
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psnet.ahrq.gov/issue/prevention-wrong-location-misadministration-through-use-intradepartmental-incident-learning
January 22, 2017 - Study
Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system.
Citation Text:
Ford E, Smith K, Harris K, et al. Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system. M…
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psnet.ahrq.gov/issue/impact-clinical-decision-support-system-high-alert-medications-prevention-prescription-errors
May 10, 2017 - Study
Impact of a clinical decision support system for high-alert medications on the prevention of prescription errors.
Citation Text:
Lee JH, Han H, Ock M, et al. Impact of a clinical decision support system for high-alert medications on the prevention of prescription errors. Int J Med …
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psnet.ahrq.gov/issue/uptake-quality-related-event-standards-practice-community-pharmacies
November 09, 2016 - Study
Uptake of quality-related event standards of practice by community pharmacies.
Citation Text:
Boyle TA, Bishop A, Overmars C, et al. Uptake of Quality-Related Event Standards of Practice by Community Pharmacies. J Pharm Pract. 2015;28(5):442-9. doi:10.1177/0897190014522066.
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psnet.ahrq.gov/issue/proceed-reasonable-care-when-legal-principles-inform-training-prevent-harm-during-childbirth
July 24, 2013 - Commentary
Proceed with reasonable care: when legal principles inform training to prevent harm during the childbirth.
Citation Text:
Petrovic M, Nicholls J, Siassakos D. Proceed with reasonable care: when legal principles inform training to prevent harm during childbirth. Best Pract Res …
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psnet.ahrq.gov/issue/identifying-resilience-system-safety-review-trauma-and-orthopaedic-theatres
October 19, 2011 - Commentary
Identifying resilience: a system safety review of trauma and orthopaedic theatres.
Citation Text:
Wills VE. Identifying resilience: a system safety review of trauma and orthopaedic theatres. Ergonomics. 2024;Epub Aug 9. doi:10.1080/00140139.2024.2343930.
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psnet.ahrq.gov/issue/operating-room-briefings-and-wrong-site-surgery
November 26, 2008 - Study
Classic
Operating room briefings and wrong-site surgery.
Citation Text:
Makary MA, Mukherjee A, Sexton B, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204(2):236-43.
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psnet.ahrq.gov/issue/effect-diagnostic-accuracy-cognitive-reasoning-tools-workplace-setting-systematic-review-and
February 02, 2022 - Review
Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review and meta-analysis.
Citation Text:
Staal J, Hooftman J, Gunput STG, et al. Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review…
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psnet.ahrq.gov/issue/developing-systematic-approach-safer-medication-use-during-pregnancy-summary-centers-disease
February 17, 2011 - Commentary
Developing a systematic approach to safer medication use during pregnancy: summary of a Centers for Disease Control and Prevention–convened meeting.
Citation Text:
Broussard CS, Frey MT, Hernandez-Diaz S, et al. Developing a systematic approach to safer medication use during p…
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psnet.ahrq.gov/issue/medical-errors-and-patient-safety-palliative-care-review-current-literature
December 04, 2016 - Review
Medical errors and patient safety in palliative care: a review of current literature.
Citation Text:
Dietz I, Borasio GD, Schneider G, et al. Medical errors and patient safety in palliative care: a review of current literature. J Palliat Med. 2010;13(12):1469-74. doi:10.1089/jpm.2…