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psnet.ahrq.gov/issue/more-teamwork-knowledge-skill-and-attitude
July 13, 2009 - Study
More to teamwork than knowledge, skill and attitude.
Citation Text:
Siassakos D, Draycott TJ, Crofts JF, et al. More to teamwork than knowledge, skill and attitude. BJOG. 2010;117(10):1262-9. doi:10.1111/j.1471-0528.2010.02654.x.
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psnet.ahrq.gov/issue/learning-defects-enhance-morbidity-and-mortality-conferences
May 20, 2009 - Commentary
Learning from defects to enhance morbidity and mortality conferences.
Citation Text:
Berenholtz SM, Hartsell TL, Pronovost P. Learning from defects to enhance morbidity and mortality conferences. Am J Med Qual. 2009;24(3):192-5. doi:10.1177/1062860609332370.
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psnet.ahrq.gov/issue/increasing-physician-reporting-diagnostic-learning-opportunities
March 23, 2022 - Study
Increasing physician reporting of diagnostic learning opportunities.
Citation Text:
Marshall TL, Ipsaro AJ, Le M, et al. Increasing physician reporting of diagnostic learning opportunities. Pediatrics. 2021;147(1):e20192400. doi:10.1542/peds.2019-2400.
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psnet.ahrq.gov/issue/association-resident-fatigue-and-distress-perceived-medical-errors
February 02, 2011 - Study
Association of resident fatigue and distress with perceived medical errors.
Citation Text:
West CP, Tan AD, Habermann TM, et al. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294-300. doi:10.1001/jama.2009.1389.
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psnet.ahrq.gov/issue/medical-error-and-decision-making-learning-past-and-present-intensive-care
June 26, 2024 - Review
Medical error and decision making: learning from the past and present in intensive care.
Citation Text:
Bucknall TK. Medical error and decision making: Learning from the past and present in intensive care. Australian Critical Care. 2010;23(3). doi:10.1016/j.aucc.2010.06.001.
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psnet.ahrq.gov/issue/framework-encouraging-patient-engagement-medical-decision-making
September 17, 2010 - Commentary
A framework for encouraging patient engagement in medical decision making.
Citation Text:
Holzmueller CG, Wu AW, Pronovost P. A framework for encouraging patient engagement in medical decision making. J Patient Saf. 2012;8(4):161-164. doi:10.1097/PTS.0b013e318267c56e.
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psnet.ahrq.gov/issue/hospital-prescribing-opioids-medicare-beneficiaries
December 04, 2016 - Study
Hospital prescribing of opioids to Medicare beneficiaries.
Citation Text:
Jena AB, Goldman D, Karaca-Mandic P. Hospital Prescribing of Opioids to Medicare Beneficiaries. JAMA Intern Med. 2016;176(7):990-7. doi:10.1001/jamainternmed.2016.2737.
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psnet.ahrq.gov/issue/state-science-evolving-perspectives-human-error
February 22, 2023 - Commentary
State of science: evolving perspectives on ‘human error’.
Citation Text:
Read GJM, Shorrock S, Walker GH, et al. State of science: evolving perspectives on ‘human error’. Ergonomics. 2021;64(9):1091-1114. doi:10.1080/00140139.2021.1953615.
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psnet.ahrq.gov/issue/pharmacy-dispensing-errors-claims-study-emphasizes-need-systematic-vigilance
April 06, 2022 - Newspaper/Magazine Article
Pharmacy dispensing errors: claims study emphasizes need for systematic vigilance.
Citation Text:
Pharmacy dispensing errors: claims study emphasizes need for systematic vigilance. Webb J. Drug Topics. March 10, 2015.
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psnet.ahrq.gov/issue/fall-prevention-hospitals-integrative-review
November 03, 2021 - Review
Fall prevention in hospitals: an integrative review.
Citation Text:
Spoelstra SL, Given BA, Given CW. Fall Prevention in Hospitals. Clin Nurs Res. 2011;21(1). doi:10.1177/1054773811418106.
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psnet.ahrq.gov/issue/identifying-quality-markers-safe-surgical-ward-interview-study-patients-clinical-staff-and
June 17, 2015 - Study
Identifying quality markers of a safe surgical ward: an interview study of patients, clinical staff, and administrators.
Citation Text:
Hassen Y, Singh P, Pucher PH, et al. Identifying quality markers of a safe surgical ward: An interview study of patients, clinical staff, and admi…
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psnet.ahrq.gov/issue/factors-associated-disclosure-medical-errors-housestaff
January 27, 2019 - Study
Factors associated with disclosure of medical errors by housestaff.
Citation Text:
Kronman AC, Paasche-Orlow MK, Orlander JD. Factors associated with disclosure of medical errors by housestaff. BMJ Qual Saf. 2011;21(4). doi:10.1136/bmjqs-2011-000084.
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psnet.ahrq.gov/issue/measured-response-identified-suicide-risk-and-violence-what-you-need-know-about-psychiatric
January 30, 2019 - Commentary
Measured response to identified suicide risk and violence: what you need to know about psychiatric patient safety.
Citation Text:
Measured response to identified suicide risk and violence: what you need to know about psychiatric patient safety. Yeager KR, Saveanu R, Roberts AR…
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psnet.ahrq.gov/issue/medical-device-safety-action-plan-protecting-patients-promoting-public-health
November 28, 2018 - Book/Report
Medical Device Safety Action Plan: Protecting Patients, Promoting Public Health.
Citation Text:
Medical Device Safety Action Plan: Protecting Patients, Promoting Public Health. Silver Spring, MD: US Food and Drug Administration; April 2018.
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psnet.ahrq.gov/issue/sources-and-types-discrepancies-between-electronic-medical-records-and-actual-outpatient
July 19, 2023 - Study
Sources and types of discrepancies between electronic medical records and actual outpatient medication use.
Citation Text:
Orrico KB. Sources and types of discrepancies between electronic medical records and actual outpatient medication use. J Manag Care Pharm. 2008;14(7):626-631…
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psnet.ahrq.gov/issue/hospital-readmissions-reduction-program-implications-pharmacy
September 23, 2020 - Commentary
Hospital Readmissions Reduction Program: implications for pharmacy.
Citation Text:
Boesen KAG, Leal S, Sheehan VC, et al. Hospital Readmissions Reduction Program: implications for pharmacy. Am J Health Syst Pharm. 2015;72(3):237-44. doi:10.2146/ajhp140177.
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psnet.ahrq.gov/issue/medical-groups-adoption-electronic-health-records-and-information-systems
January 14, 2011 - Study
Medical groups' adoption of electronic health records and information systems.
Citation Text:
Gans DN, Kralewski J, Hammons T, et al. Medical Groups’ Adoption Of Electronic Health Records And Information Systems. Health Aff. 2005;24(5):1323-1333. doi:10.1377/hlthaff.24.5.1323.
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psnet.ahrq.gov/issue/winning-battle-standardization
March 02, 2022 - Newspaper/Magazine Article
Winning the battle for standardization.
Citation Text:
Durkee RP, Richard LW. Winning the battle for standardization. The U.S. Army Medical Department examines the EMR to develop a standardized process for medication reconciliation documentation. Health Manag…
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psnet.ahrq.gov/issue/advancement-toward-high-reliability-healthcare-awards
June 08, 2011 - January 21, 2009
Teamwork is associated with reduced hospital staff burnout at military
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psnet.ahrq.gov/issue/fatal-drug-mix-exposes-hospital-flaws
March 02, 2016 - July 10, 2018
Teamwork is associated with reduced hospital staff burnout at military