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  1. How a series of errors led to recurrent hypoglycemia. | PSNet

    psnet.ahrq.gov/issue/how-series-errors-led-recurrent-hypoglycemia
    April 23, 2014 - Commentary How a series of errors led to recurrent hypoglycemia. Citation Text: Singh R. How a series of errors led to recurrent hypoglycemia. J Fam Pract. 2006;55(6):489-97. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…

  2. Appendix E. Culture Type Map to Procedure Types | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/final-reports/ssi/ssiape.html
    April 01, 2018 - Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection Appendix E. Culture Type Map to Procedure Types Previous Page Next Page Table of Contents Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection Executive Summary Chapte…

  3. Appendix F. Algorithms | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/final-reports/ssi/ssiapf.html
    April 01, 2018 - Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection Appendix F. Algorithms Previous Page Next Page Table of Contents Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection Executive Summary Chapter 1. Administration Cha…

  4. Perioperative pharmacology: a framework for perioperative medication safety. | PSNet

    psnet.ahrq.gov/issue/perioperative-pharmacology-framework-perioperative-medication-safety
    December 19, 2012 - Commentary Perioperative pharmacology: a framework for perioperative medication safety. Citation Text: Hicks RW, Wanzer LJ, Goeckner BL. Perioperative Pharmacology: A Framework for Perioperative Medication Safety. AORN J. 2010;93(1):136-145. doi:10.1016/j.aorn.2010.08.020. Copy Citat…

  5. Tubing misconnections: normalization of deviance. | PSNet

    psnet.ahrq.gov/issue/tubing-misconnections-normalization-deviance
    December 16, 2015 - Review Tubing misconnections: normalization of deviance. Citation Text: Simmons D, Symes L, Guenter P, et al. Tubing misconnections: normalization of deviance. Nutr Clin Pract. 2011;26(3):286-293. doi:10.1177/0884533611406134. Copy Citation Format: DOI Google Scholar PubM…

  6. Reducing surgical complications. | PSNet

    psnet.ahrq.gov/issue/reducing-surgical-complications
    January 03, 2018 - Commentary Reducing surgical complications. Citation Text: Griffin F. Reducing surgical complications. Jt Comm J Qual Patient Saf. 2007;33(11):660-5. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downlo…

  7. Trends in adverse events over time: why are we not improving? | PSNet

    psnet.ahrq.gov/issue/trends-adverse-events-over-time-why-are-we-not-improving
    October 02, 2019 - Commentary Trends in adverse events over time: why are we not improving? Citation Text: Shojania KG, Thomas EJ. Trends in adverse events over time: why are we not improving? BMJ Qual Saf. 2013;22(4):273-7. doi:10.1136/bmjqs-2013-001935. Copy Citation Format: DOI Google Sc…

  8. FDA Guidance Document: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. | PSNet

    psnet.ahrq.gov/issue/fda-guidance-document-hospital-bed-system-dimensional-and-assessment-guidance-reduce
    July 01, 2009 - Organizational Policy/Guidelines FDA Guidance Document: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. Citation Text: FDA Guidance Document: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. Rockville MD: Center for Devices a…

  9. Reporting near-miss events in nursing homes. | PSNet

    psnet.ahrq.gov/issue/reporting-near-miss-events-nursing-homes
    January 24, 2018 - Commentary Reporting near-miss events in nursing homes. Citation Text: Wagner LM, Capezuti E, Ouslander JG. Reporting near-miss events in nursing homes. Nurs Outlook. 2006;54(2). doi:10.1016/j.outlook.2006.01.003. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3…

  10. When should a leader apologize—and when not? | PSNet

    psnet.ahrq.gov/issue/when-should-leader-apologize-and-when-not
    October 07, 2020 - Commentary When should a leader apologize—and when not? Citation Text: Kellerman B. When should a leader apologize and when not? Harv Bus Rev. 2006;84(4):72-81; 148. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

  11. Clinical-Community Relationships Measures Expert Panel | Agency for Healthcare Research and Quality

    www.ahrq.gov/prevention/resources/chronic-care/ccrm-atlas-suppl/ccrm-app-panel.html
    October 01, 2013 - Potential Measures for Clinical-Community Relationships Clinical-Community Relationships Measures Expert Panel Previous Page   Table of Contents Potential Measures for Clinical-Community Relationships Acknowledgements Executive Summary Introduction Potential Measure Development Methodology …

  12. Patient safety answers require outreach, in-reach, and partnerships. | PSNet

    psnet.ahrq.gov/issue/patient-safety-answers-require-outreach-reach-and-partnerships
    August 23, 2023 - Commentary Patient safety answers require outreach, in-reach, and partnerships. Citation Text: Burt HA. Patient Safety Answers Require Outreach, In-reach, and Partnerships. J Hosp Librariansh. 2011;11(4). doi:10.1080/15323269.2011.611436. Copy Citation Format: DOI Google …

  13. Medication bar coding: to scan or not to scan? | PSNet

    psnet.ahrq.gov/issue/medication-bar-coding-scan-or-not-scan
    October 19, 2022 - Commentary Medication bar coding: to scan or not to scan? Citation Text: Galvin L, McBeth S, Hasdorff C, et al. Medication bar coding: to scan or not to scan? Comput Inform Nurs. 2007;25(2):86-92. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7…

  14. Safety Considerations for Product Design to Minimize Medication Errors: Guidance for Industry. | PSNet

    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…

  15. The Science of Safety:​ Principles in Practice | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/mrsa-prevention/surgery/science-of-safety.html
    April 01, 2025 - MRSA Prevention Toolkit: Targeting SSI The Science of Safety:​ Principles in Practice Previous Page Next Page Table of Contents MRSA Prevention Toolkit: Targeting SSI The Four Key Strategies of MRSA Prevention: Targeting SSI MRSA and SSI Prevention Phases The Evidence for MRSA Decolonization …

  16. Implement strategies to prevent persistent medication errors and hazards. | PSNet

    psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards
    March 14, 2023 - Newspaper/Magazine Article Implement strategies to prevent persistent medication errors and hazards. Citation Text: Implement strategies to prevent persistent medication errors and hazards. ISMP Medication Safety Alert! Acute care edition. March 23, 2023;28(6):1-4. Copy Citation …

  17. Analysis of transdermal medication patch errors uncovers a “patchwork” of safety challenges. | PSNet

    psnet.ahrq.gov/issue/analysis-transdermal-medication-patch-errors-uncovers-patchwork-safety-challenges
    March 03, 2021 - Newspaper/Magazine Article Analysis of transdermal medication patch errors uncovers a “patchwork” of safety challenges. Citation Text: Analysis of transdermal medication patch errors uncovers a “patchwork” of safety challenges. ISMP Medication Safety Alert! Acute Care. March 11, 2021;26(…

  18. Patient safety functions of state medical boards in the United States. | PSNet

    psnet.ahrq.gov/issue/patient-safety-functions-state-medical-boards-united-states
    April 13, 2022 - Commentary Patient safety functions of state medical boards in the United States. Citation Text: Patient safety functions of state medical boards in the United States. Roy CG. Yale J Biol Med. 2021;94(1):165-173.  Copy Citation Save Save to your library …

  19. The incidence of diagnostic error in medicine. | PSNet

    psnet.ahrq.gov/issue/incidence-diagnostic-error-medicine
    July 15, 2015 - Review The incidence of diagnostic error in medicine. Citation Text: Graber ML. The incidence of diagnostic error in medicine. BMJ Qual Saf. 2013;22 Suppl 2:ii21-ii27. doi:10.1136/bmjqs-2012-001615. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML End…

  20. Provider Burden | Digital Healthcare Research

    digital.ahrq.gov/health-care-theme/provider-burden
    January 01, 2023 - Provider Burden Artificial Intelligence and Human Factors in Healthcare Quality & Safety Description Using a conference model, this study convenes a multidisciplinary group of experts to explore the integration of human factors engineering approaches in the implementation of a…
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