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  1. The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives. | PSNet

    psnet.ahrq.gov/issue/vha-new-england-medication-error-prevention-initiative-model-long-term-improvement
    January 04, 2017 - Commentary The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives. Citation Text: Lesar TS, Anderson ER, Fields J, et al. The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives…

  2. Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection. | PSNet

    psnet.ahrq.gov/issue/potentially-dangerous-confusion-between-bloxiverz-neostigmine-injection-and-vazculep
    July 08, 2015 - Press Release/Announcement Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection. Citation Text: Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection. National Alert Net…

  3. Challenges faced in providing safe care in rural perinatal settings. | PSNet

    psnet.ahrq.gov/issue/challenges-faced-providing-safe-care-rural-perinatal-settings
    June 14, 2017 - Study Challenges faced in providing safe care in rural perinatal settings. Citation Text: Jukkala AM, Kirby RS. Challenges faced in providing safe care in rural perinatal settings. MCN Am J Matern Child Nurs. 2009;34(6):365-371. doi:10.1097/01.NMC.0000363685.20315.0e. Copy Citation …

  4. I-CaRe: a case review tool focused on improving inpatient care. | PSNet

    psnet.ahrq.gov/issue/i-care-case-review-tool-focused-improving-inpatient-care
    February 18, 2011 - Commentary I-CaRe: a case review tool focused on improving inpatient care. Citation Text: Lee JH, Vidyarthi A, Sehgal NL, et al. I-CaRe: a case review tool focused on improving inpatient care. Jt Comm J Qual Patient Saf. 2009;35(2):115-119, 61. Copy Citation Format: Googl…

  5. Interdisciplinary collaboration to maintain a culture of safety in a labor and delivery setting. | PSNet

    psnet.ahrq.gov/issue/interdisciplinary-collaboration-maintain-culture-safety-labor-and-delivery-setting
    January 02, 2017 - Commentary Interdisciplinary collaboration to maintain a culture of safety in a labor and delivery setting. Citation Text: Burke C, Grobman WA, Miller D. Interdisciplinary collaboration to maintain a culture of safety in a labor and delivery setting. J Perinat Neonatal Nurs. 2013;27(2):…

  6. Teamwork behaviours and errors during neonatal resuscitation. | PSNet

    psnet.ahrq.gov/issue/teamwork-behaviours-and-errors-during-neonatal-resuscitation
    September 13, 2011 - Study Teamwork behaviours and errors during neonatal resuscitation. Citation Text: Williams AL, Lasky RE, Dannemiller JL, et al. Teamwork behaviours and errors during neonatal resuscitation. Qual Saf Health Care. 2010;19(1):60-4. doi:10.1136/qshc.2007.025320. Copy Citation Format…

  7. The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety. | PSNet

    psnet.ahrq.gov/issue/financial-and-human-cost-medical-error-and-how-massachusetts-can-lead-way-patient-safety
    April 03, 2019 - Book/Report The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety. Citation Text: The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety. Boston, MA: Betsy Lehman Center for Patient Saf…

  8. Inappropriate surgeries resulting from misdiagnosis of early amyotrophic lateral sclerosis. | PSNet

    psnet.ahrq.gov/issue/inappropriate-surgeries-resulting-misdiagnosis-early-amyotrophic-lateral-sclerosis
    October 31, 2014 - Study Inappropriate surgeries resulting from misdiagnosis of early amyotrophic lateral sclerosis. Citation Text: Srinivasan J, Scala S, Jones R, et al. Inappropriate surgeries resulting from misdiagnosis of early amyotrophic lateral sclerosis. Muscle Nerve. 2006;34(3):359-60. Copy Ci…

  9. Medicaid program; payment adjustment for provider-preventable conditions including health care–acquired conditions. | PSNet

    psnet.ahrq.gov/issue/medicaid-program-payment-adjustment-provider-preventable-conditions-including-health-care
    July 07, 2021 - Government Resource Medicaid program; payment adjustment for provider-preventable conditions including health care–acquired conditions. Citation Text: Medicaid program; payment adjustment for provider-preventable conditions including health care–acquired conditions. Centers for Medic…

  10. Telehealth. | PSNet

    psnet.ahrq.gov/issue/telehealth
    January 27, 2019 - Commentary Telehealth. Citation Text: Tuckson R, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377(16):1585-1592. doi:10.1056/NEJMsr1503323. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Do…

  11. Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. | PSNet

    psnet.ahrq.gov/issue/developing-indicators-inpatient-adverse-drug-events-through-nonlinear-analysis-using
    December 23, 2011 - Study Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. Citation Text: Nebeker JR, Yarnold PR, Soltysik RC, et al. Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. Med…

  12. Preventing surgical site infections: implementing strategies throughout the perioperative continuum. | PSNet

    psnet.ahrq.gov/issue/preventing-surgical-site-infections-implementing-strategies-throughout-perioperative
    January 15, 2025 - Commentary Preventing surgical site infections: implementing strategies throughout the perioperative continuum. Citation Text: Rosa R, Sposato K, Abbo LM. Preventing surgical site infections: implementing strategies throughout the perioperative continuum. AORN J. 2023;117(5):300-311. doi…

  13. FDA Advise-ERR: reported medication errors with Veklury (remdesivir) emergency use authorization. | PSNet

    psnet.ahrq.gov/issue/fda-advise-err-reported-medication-errors-veklury-remdesivir-emergency-use-authorization
    July 01, 2020 - Newspaper/Magazine Article FDA Advise-ERR: reported medication errors with Veklury (remdesivir) emergency use authorization. Citation Text: FDA Advise-ERR: reported medication errors with Veklury (remdesivir) emergency use authorization. ISMP Medication Safety Alert! Acute care edition.&…

  14. Patient safety in dermatology: a ten-year update. | PSNet

    psnet.ahrq.gov/issue/patient-safety-dermatology-ten-year-update
    February 17, 2010 - Review Patient safety in dermatology: a ten-year update. Citation Text: Patient safety in dermatology: a ten-year update. Patel J, Otto E, Taylor JS, et al. Dermatol Online J. 2021;27(3). Copy Citation Save Save to your library Print Download PDF …

  15. Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surgical patients. | PSNet

    psnet.ahrq.gov/issue/beyond-our-walls-impact-patient-and-provider-coordination-across-continuum-outcomes-surgical
    March 24, 2021 - Study Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surgical patients. Citation Text: Weinberg DB, Gittell JH, Lusenhop W, et al. Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surg…

  16. Safety of clinical and non-clinical decision makers in telephone triage: a narrative review. | PSNet

    psnet.ahrq.gov/issue/safety-clinical-and-non-clinical-decision-makers-telephone-triage-narrative-review
    July 05, 2017 - Review Safety of clinical and non-clinical decision makers in telephone triage: a narrative review. Citation Text: Wheeler SQ, Greenberg ME, Mahlmeister L, et al. Safety of clinical and non-clinical decision makers in telephone triage: a narrative review. J Telemed Telecare. 2015;21(6):3…

  17. Human factors in surgery: from Three Mile Island to the operating room. | PSNet

    psnet.ahrq.gov/issue/human-factors-surgery-three-mile-island-operating-room
    July 12, 2019 - Review Human factors in surgery: from Three Mile Island to the operating room. Citation Text: D'Addessi A, Bongiovanni L, Volpe A, et al. Human factors in surgery: from Three Mile Island to the operating room. Urol Int. 2009;83(3):249-57. doi:10.1159/000241662. Copy Citation Form…

  18. ACOG Committee Opinion #621: patient safety and health information technology. | PSNet

    psnet.ahrq.gov/issue/acog-committee-opinion-621-patient-safety-and-health-information-technology
    May 22, 2019 - Commentary ACOG Committee Opinion #621: patient safety and health information technology. Citation Text: Improvement C on PS and Q, Management C on P. Committee opinion no. 621: Patient safety and health information technology. Obstet Gynecol. 2015;125(1):282-3. doi:10.1097/01.AOG.000045…

  19. Opportunities to improve informed consent with AHRQ training modules. | PSNet

    psnet.ahrq.gov/issue/opportunities-improve-informed-consent-ahrq-training-modules
    December 31, 2014 - Study Opportunities to improve informed consent with AHRQ training modules. Citation Text: Shoemaker SJ, Brach C, Edwards A, et al. Opportunities to Improve Informed Consent with AHRQ Training Modules. Jt Comm J Qual Patient Saf. 2018;44(6):343-352. doi:10.1016/j.jcjq.2017.11.010. Copy…

  20. Electronic health records and National Patient-Safety Goals. | PSNet

    psnet.ahrq.gov/issue/electronic-health-records-and-national-patient-safety-goals
    December 06, 2023 - Commentary Electronic health records and National Patient-Safety Goals. Citation Text: Sittig DF, Singh H. Electronic Health Records and National Patient-Safety Goals. New England Journal of Medicine. 2012;367(19). doi:10.1056/nejmsb1205420. Copy Citation Format: DOI Goog…
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