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psnet.ahrq.gov/node/36778/psn-pdf
August 26, 2011 - What medications does your patient take? Enhancing
medication safety in the outpatient setting.
August 26, 2011
Institute for Healthcare Improvement; IHI
https://psnet.ahrq.gov/issue/what-medications-does-your-patient-take-enhancing-medication-safety-
outpatient-setting
This article discusses the importance of me…
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psnet.ahrq.gov/primer/measurement-patient-safety
September 15, 2024 - Measurement is used for a variety of purposes: to evaluate the effectiveness of safety interventions,
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psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - Medication Mix-Up: From Bad to Worse
Citation Text:
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/40067/psn-pdf
December 08, 2010 - Slowing down to stay out of trouble in the operating
room: remaining attentive in automaticity.
December 8, 2010
Moulton C-A, Regehr G, Lingard LA, et al. Slowing down to stay out of trouble in the operating room:
remaining attentive in automaticity. Acad Med. 2010;85(10):1571-7. doi:10.1097/ACM.0b013e3181f073dd.
…
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psnet.ahrq.gov/node/47921/psn-pdf
June 18, 2019 - Using incident reports to assess communication failures
and patient outcomes.
June 18, 2019
Umberfield E, Ghaferi AA, Krein SL, et al. Using Incident Reports to Assess Communication Failures and
Patient Outcomes. Jt Comm J Qual Patient Saf. 2019;45(6):406-413. doi:10.1016/j.jcjq.2019.02.006.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/37920/psn-pdf
May 24, 2015 - Functional health literacy and understanding of
medications at discharge.
May 24, 2015
Maniaci MJ, Heckman MG, Dawson NL. Functional health literacy and understanding of medications at
discharge. Mayo Clin Proc. 2008;83(5):554-8. doi:10.4065/83.5.554.
https://psnet.ahrq.gov/issue/functional-health-literacy-and-und…
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psnet.ahrq.gov/issue/what-medications-does-your-patient-take-enhancing-medication-safety-outpatient-setting
January 08, 2020 - Commentary
What medications does your patient take? Enhancing medication safety in the outpatient setting.
Citation Text:
What medications does your patient take? Enhancing medication safety in the outpatient setting. Institute for Healthcare Improvement; IHI
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psnet.ahrq.gov/issue/using-good-design-eliminate-medical-errors
December 09, 2020 - Newspaper/Magazine Article
Using good design to eliminate medical errors.
Citation Text:
Using good design to eliminate medical errors. Jaffe E.
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psnet.ahrq.gov/node/34638/psn-pdf
December 23, 2008 - What is accountability in health care?
December 23, 2008
Emanuel EJ, Emanuel LL. What is accountability in health care? Ann Intern Med. 1996;124(2):229-239.
https://psnet.ahrq.gov/issue/what-accountability-health-care
This perspective details the concepts surrounding “accountability” in health care. The discussion …
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psnet.ahrq.gov/glossary/handoffs-and-handovers
September 13, 2021 - Handoffs and Handovers
September 13, 2021
Anonymous (not verified)
See Primer . The process when one health care professional updates another on the status of one or more patients for the purpose of taking over their care. Typical examples involve a physician who has been on call overnight telling an incoming …
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psnet.ahrq.gov/issue/identifying-and-mapping-measures-medication-safety-during-transfer-care-digital-era-scoping
July 24, 2024 - Review
Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review.
Citation Text:
Leon C, Hogan H, Jani YH. Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literatur…
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psnet.ahrq.gov/node/44087/psn-pdf
November 16, 2015 - Teaching a 'good' ward round.
November 16, 2015
Powell N, Bruce CG, Redfern O. Teaching a 'good' ward round. Clin Med (Lond). 2015;15(2):135-138.
doi:10.7861/clinmedicine.15-2-135.
https://psnet.ahrq.gov/issue/teaching-good-ward-round
Ward rounds, while an important educational activity, may not receive the attent…
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psnet.ahrq.gov/node/44918/psn-pdf
April 13, 2016 - National Reporting and Learning System Research and
Development.
April 13, 2016
Mayer E, Flott K, Callahan R, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research
Centre; 2016.
https://psnet.ahrq.gov/issue/national-reporting-and-learning-system-research-and-development
Incident reporting has a…
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psnet.ahrq.gov/node/43647/psn-pdf
November 12, 2014 - Mid Staffordshire NHS Foundation Trust Quality Report.
November 12, 2014
Newcastle Upon Tyne, UK: Care Quality Commission; October 9, 2014.
https://psnet.ahrq.gov/issue/mid-staffordshire-nhs-foundation-trust-quality-report
The Mid Staffordshire Trust has been under much scrutiny in recent years. This report highlig…
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psnet.ahrq.gov/node/46380/psn-pdf
September 06, 2017 - What defines a high-performing health system: a
systematic review.
September 6, 2017
Ahluwalia SC, Damberg CL, Silverman M, et al. What Defines a High-Performing Health Care Delivery
System: A Systematic Review. Jt Comm J Qual Patient Saf. 2017;43(9):450-459.
doi:10.1016/j.jcjq.2017.03.010.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/45506/psn-pdf
November 30, 2016 - Is an indication-based prescribing system in our future?
November 30, 2016
ISMP Medication Safety Alert! Acute Care Edition. November 17, 2016;21:1-5.
https://psnet.ahrq.gov/issue/indication-based-prescribing-system-our-future
Health information technology has enhanced prescribers' ability to document the purpose o…
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psnet.ahrq.gov/node/43565/psn-pdf
March 22, 2016 - The role of failure mode and effects analysis in health
care.
March 22, 2016
Fibuch E, Ahmed A. The role of failure mode and effects analysis in health care. Physician Exec.
2014;40(4):28-32.
https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care
Failure mode and effects analysis (FMEA) h…
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psnet.ahrq.gov/node/48098/psn-pdf
July 10, 2019 - How often do prescribers include indications in drug
orders? Analysis of 4 million outpatient prescriptions.
July 10, 2019
Salazar A, Karmiy SJ, Forsythe KJ, et al. How often do prescribers include indications in drug orders?
Analysis of 4 million outpatient prescriptions. Am J Health Syst Pharm. 2019;76(13):970-97…
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psnet.ahrq.gov/issue/health-systems-and-hospitals-pursuit-high-reliability
October 23, 2019 - Newspaper/Magazine Article
Health systems and hospitals in pursuit of high reliability.
Citation Text:
Health systems and hospitals in pursuit of high reliability. Cheney C. HealthLeaders Media. April 17, 2019.
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psnet.ahrq.gov/issue/reading-signals-maternity-and-neonatal-services-east-kent-report-independent-investigation
February 19, 2020 - Book/Report
'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation.
Citation Text:
'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation. Kirkup B. Department of Healt…