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psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
August 01, 2012 - NC : That is a very timely question. Most places I would say not.
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - through small bowel); satisfaction of search , in which accompanying findings not specific to the primary question
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - SPOTLIGHT CASE
Signout Fallout
Citation Text:
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/issue/e-prescribing-and-medication-safety-community-settings-rapid-scoping-review
January 22, 2025 - Review
E-prescribing and medication safety in community settings: a rapid scoping review.
Citation Text:
Cassidy CE, Boulos L, McConnell E, et al. E-prescribing and medication safety in community settings: a rapid scoping review. Explor Res Clin Soc Pharm. 2023;12:100365. doi:10.1016/j.r…
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psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
April 01, 2015 - Medication Reconciliation Victory After an Avoidable Error
Citation Text:
Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/issue/psychological-safety-scale-safety-communication-operational-reliability-and-engagement-score
August 24, 2022 - Study
The Psychological Safety Scale of the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey: a brief, diagnostic, and actionable metric for the ability to speak up in healthcare settings.
Citation Text:
Adair KC, Heath A, Frye MA, et al. The Psychological S…
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psnet.ahrq.gov/issue/how-medical-jargon-can-make-covid-health-disparities-even-worse
July 28, 2021 - Newspaper/Magazine Article
How medical jargon can make COVID health disparities even worse.
Citation Text:
How medical jargon can make COVID health disparities even worse. Kritz F. Health Shots. National Public Radio; May 24, 2021.
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psnet.ahrq.gov/issue/doctors-must-stop-tuning-out-black-women-it-happened-me-pregnant-ob-gyn
June 24, 2020 - Newspaper/Magazine Article
Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN.
Citation Text:
Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN. Gillispie-Bell V. USA Today. April 14, 2023.
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psnet.ahrq.gov/issue/long-term-trends-psychotropic-drug-use-nursing-homes
May 25, 2022 - Book/Report
Long-Term Trends of Psychotropic Drug Use in Nursing Homes.
Citation Text:
Long-Term Trends of Psychotropic Drug Use in Nursing Homes. Grimm CA. Washington DC: Office of the Inspector General; Nov 2022. Report no. OEI-07-20-00500.
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psnet.ahrq.gov/issue/public-has-been-forgiving-hospitals-got-some-things-wrong
April 03, 2019 - Newspaper/Magazine Article
The public has been forgiving. But hospitals got some things wrong.
Citation Text:
Ofri D. The public has been forgiving. But hospitals got some things wrong. New York Times. 2020; May 21.
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psnet.ahrq.gov/issue/safety-considerations-product-design-minimize-medication-errors-guidance-industry
January 13, 2021 - Book/Report
Safety Considerations for Product Design to Minimize Medication Errors: Guidance for Industry.
Citation Text:
Safety Considerations for Product Design to Minimize Medication Errors: Guidance for Industry. Rockville, MD: Center for Drug Evaluation and Research, US Food and Dru…
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psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients-tackling-three-tough-cases
December 19, 2018 - Commentary
Disclosing harmful medical errors to patients: tackling three tough cases.
Citation Text:
Gallagher TH, Bell SK, Smith KM, et al. Disclosing harmful medical errors to patients: tackling three tough cases. Chest. 2009;136(3):897-903. doi:10.1378/chest.09-0030.
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psnet.ahrq.gov/issue/think-health-care-workers-are-tested-often-coronavirus-think-again
July 29, 2020 - Audiovisual
Think health care workers are tested often for the Coronavirus? Think again.
Citation Text:
Think health care workers are tested often for the Coronavirus? Think again. Wamsley L. National Public Radio and WBUR. December 7, 2020.
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psnet.ahrq.gov/issue/partnering-families-and-patient-advocates-another-line-defense-adverse-event-surveillance
September 11, 2019 - Newspaper/Magazine Article
Partnering with families and patient advocates: another line of defense in adverse event surveillance.
Citation Text:
Partnering with families and patient advocates: another line of defense in adverse event surveillance. ISMP Medication Safety Alert! Acute Care…
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psnet.ahrq.gov/issue/speaking-safety-its-not-simple
April 04, 2018 - Newspaper/Magazine Article
Speaking up for safety—it’s not simple.
Citation Text:
Speaking up for safety—it’s not simple. Liberatore K. PA-PSRS Patient Saf Advis. 2018;15(3).
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psnet.ahrq.gov/issue/association-between-sleep-health-and-rates-self-reported-medical-errors-intern-physicians
February 07, 2024 - Study
Association between sleep health and rates of self-reported medical errors in intern physicians: an ancillary analysis of the Intern Health Study.
Citation Text:
Hassinger AB, Velez C, Wang J, et al. Association between sleep health and rates of self-reported medical errors in inte…
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psnet.ahrq.gov/issue/video-based-communication-assessment-physician-error-disclosure-skills-crowdsourced-laypeople
August 21, 2024 - Study
Video-based communication assessment of physician error disclosure skills by crowdsourced laypeople and patient advocates who experienced medical harm: reliability assessment with generalizability theory.
Citation Text:
White AA, King AM, D’Addario AE, et al. Video-based communicat…
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psnet.ahrq.gov/issue/safety-enhancements-every-hospital-must-consider-wake-another-tragic-neuromuscular-blocker
June 19, 2019 - Newspaper/Magazine Article
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
Citation Text:
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event. ISMP Medication Safety Alert! Acute Ca…
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psnet.ahrq.gov/issue/how-policy-makers-can-smooth-way-communication-and-resolution-programs
December 19, 2018 - Commentary
How policy makers can smooth the way for communication-and-resolution programs.
Citation Text:
Sage WM, Gallagher TH, Armstrong S, et al. How policy makers can smooth the way for communication-and- resolution programs. Health Aff (Millwood). 2014;33(1):11-9. doi:10.1377/hlthaf…
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psnet.ahrq.gov/issue/enhancing-effectiveness-team-debriefings-medical-simulation-more-best-practices
March 17, 2021 - Commentary
Enhancing the effectiveness of team debriefings in medical simulation: more best practices.
Citation Text:
Lyons R, Lazzara EH, Benishek LE, et al. Enhancing the effectiveness of team debriefings in medical simulation: more best practices. Jt Comm J Qual Patient Saf. 2015;41(3…