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psnet.ahrq.gov/issue/systems-approach-sharp-end
April 21, 2021 - Commentary
The systems approach at the sharp end.
Citation Text:
Cross SRH. The systems approach at the sharp end. Future Healthc J. 2019;5(3):176-180. doi:10.7861/futurehosp.5-3-176.
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psnet.ahrq.gov/issue/changes-nursing-practice-associations-responses-and-coping-errors
October 19, 2022 - Study
Changes in nursing practice: associations with responses to and coping with errors.
Citation Text:
Karga M, Kiekkas P, Aretha D, et al. Changes in nursing practice: associations with responses to and coping with errors. J Clin Nurs. 2011;20(21-22):3246-55. doi:10.1111/j.1365-2702…
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psnet.ahrq.gov/issue/direct-oral-anticoagulants-review-common-medication-errors
January 12, 2022 - Review
Emerging Classic
Direct oral anticoagulants: a review of common medication errors.
Citation Text:
Barr D, Epps QJ. Direct oral anticoagulants: a review of common medication errors. J Thromb Thrombolysis. 2019;47(1):146-154. doi:10.1007/s11239-018-1752-9. …
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psnet.ahrq.gov/issue/rural-community-members-perceptions-harm-medical-mistakes-high-plains-research-network-hprn
February 03, 2011 - Study
Rural community members' perceptions of harm from medical mistakes: a High Plains Research Network (HPRN) study.
Citation Text:
Van Vorst RF, Araya-Guerra R, Felzien M, et al. Rural community members' perceptions of harm from medical mistakes: a High Plains Research Network (HPRN…
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psnet.ahrq.gov/issue/patient-safety-inpatient-psychiatry-remaining-frontier-health-policy
October 19, 2022 - Commentary
Patient safety in inpatient psychiatry: a remaining frontier for health policy.
Citation Text:
Shields MC, Stewart MT, Delaney KR. Patient Safety In Inpatient Psychiatry: A Remaining Frontier For Health Policy. Health Aff (Millwood). 2018;37(11):1853-1861. doi:10.1377/hlthaff.…
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psnet.ahrq.gov/issue/cognitive-error-academic-emergency-department
July 29, 2020 - Study
Cognitive error in an academic emergency department.
Citation Text:
Schnapp BH, Sun JE, Kim JL, et al. Cognitive error in an academic emergency department. Diagnosis (Berl). 2018;5(3):135-142. doi:10.1515/dx-2018-0011.
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psnet.ahrq.gov/issue/preventing-delayed-and-missed-care-applying-artificial-intelligence-trigger-radiology-imaging
April 06, 2022 - Study
Preventing delayed and missed care by applying artificial intelligence to trigger radiology imaging follow-up.
Citation Text:
Domingo J, Galal G, Huang J. Preventing delayed and missed care by applying artificial intelligence to trigger radiology imaging follow-up. NEJM Catal Innov…
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psnet.ahrq.gov/issue/targeting-zero-harm-stretch-goal-risks-breaking-spring
December 01, 2021 - Commentary
Targeting zero harm: a stretch goal that risks breaking the spring.
Citation Text:
Meddings J, Saint S, Lilford RJ, et al. Targeting zero harm: a stretch goal that risks breaking the spring. NEJM Catal Innov Care Deliv. 2020;1(4). doi:10.1056/cat.20.0354.
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psnet.ahrq.gov/issue/strategies-detecting-adverse-drug-events-among-older-persons-ambulatory-setting
February 09, 2011 - Study
Strategies for detecting adverse drug events among older persons in the ambulatory setting.
Citation Text:
Field T, Gurwitz JH, Harrold LR, et al. Strategies for detecting adverse drug events among older persons in the ambulatory setting. J Am Med Inform Assoc. 2004;11(6):492-8. …
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psnet.ahrq.gov/issue/effect-communication-errors-during-calls-antimicrobial-stewardship-program
June 22, 2022 - Study
Effect of communication errors during calls to an antimicrobial stewardship program.
Citation Text:
Linkin DR, Fishman NO, Landis R, et al. Effect of communication errors during calls to an antimicrobial stewardship program. Infect Control Hosp Epidemiol. 2007;28(12):1374-1381.
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psnet.ahrq.gov/issue/institute-medicine-report-medical-errors-could-it-do-harm
February 18, 2011 - Commentary
Classic
The Institute of Medicine report on medical errors—could it do harm?
Citation Text:
Brennan TA. The Institute of Medicine report on medical errors--could it do harm? N Engl J Med. 2002;342(15):1123-1125. doi:10.1056/nejm200004133421510.
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psnet.ahrq.gov/issue/requirements-implementing-just-culture-within-healthcare-organisations-integrative-review
October 31, 2014 - Review
Requirements for implementing a 'just culture' within healthcare organisations: an integrative review.
Citation Text:
Murray JS, Lee J, Larson S, et al. Requirements for implementing a ‘just culture’ within healthcare organisations: an integrative review. BMJ Open Qual. 2023;12(2)…
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psnet.ahrq.gov/issue/diagnostic-errors-obstetric-morbidity-and-mortality-methods-and-challenges-seeking-diagnostic
May 18, 2022 - Commentary
Diagnostic errors in obstetric morbidity and mortality: methods for and challenges in seeking diagnostic excellence.
Citation Text:
Krenitsky NM, Perez-Urbano I, Goffman D. Diagnostic errors in obstetric morbidity and mortality: methods for and challenges in seeking diagnostic…
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psnet.ahrq.gov/issue/scope-drug-related-problems-home-care-setting
February 16, 2011 - Review
The scope of drug-related problems in the home care setting.
Citation Text:
Meyer-Massetti C, Meier CR, Guglielmo J. The scope of drug-related problems in the home care setting. Int J Clin Pharm. 2018;40(2):325-334. doi:10.1007/s11096-017-0581-9.
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psnet.ahrq.gov/issue/intravenous-fluid-prescribing-errors-children-mixed-methods-analysis-critical-incidents
June 14, 2023 - Study
Intravenous fluid prescribing errors in children: mixed methods analysis of critical incidents.
Citation Text:
Conn RL, McVea S, Carrington A, et al. Intravenous fluid prescribing errors in children: Mixed methods analysis of critical incidents. PLoS One. 2017;12(10):e0186210. doi:…
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psnet.ahrq.gov/issue/strategies-reduce-risk-iatrogenic-illness-complex-older-adults
January 12, 2022 - Review
Strategies to reduce the risk of iatrogenic illness in complex older adults.
Citation Text:
Onder G, van der Cammen TJM, Petrovic M, et al. Strategies to reduce the risk of iatrogenic illness in complex older adults. Age Ageing. 2013;42(3):284-91. doi:10.1093/ageing/aft038.
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psnet.ahrq.gov/issue/effect-social-influences-pharmacists-intention-report-adverse-drug-events
November 13, 2019 - Study
Effect of social influences on pharmacists' intention to report adverse drug events.
Citation Text:
Gavaza P, Brown CM, Lawson KA, et al. Effect of social influences on pharmacists' intention to report adverse drug events. J Am Pharm Assoc (2003). 2012;52(5):622-629.
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psnet.ahrq.gov/issue/scaffolding-our-systems-patients-and-families-reaching-source-healthcare-resilience
February 23, 2022 - Commentary
Scaffolding our systems? Patients and families 'reaching in' as a source of healthcare resilience.
Citation Text:
O'Hara JK, Aase K, Waring J. Scaffolding our systems? Patients and families 'reaching in' as a source of healthcare resilience. BMJ Qual Saf. 2019;28(1):3-6. doi:1…
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psnet.ahrq.gov/issue/safe-practice-standard-barcode-technology
September 21, 2022 - Review
A safe practice standard for barcode technology.
Citation Text:
Leung AA, Denham CR, Gandhi TK, et al. A safe practice standard for barcode technology. J Patient Saf. 2015;11(2):89-99. doi:10.1097/PTS.0000000000000049.
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psnet.ahrq.gov/issue/decreasing-surgical-site-infections-developing-high-reliability-culture
July 05, 2017 - Commentary
Decreasing surgical site infections by developing a high reliability culture.
Citation Text:
Pettis AM. Decreasing Surgical Site Infections by Developing a High Reliability Culture. AORN J. 2018;108(6):644-650. doi:10.1002/aorn.12416.
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