-
psnet.ahrq.gov/node/46079/psn-pdf
June 28, 2017 - Death due to pharmacy compounding error reinforces
need for safety focus.
June 28, 2017
ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4.
https://psnet.ahrq.gov/issue/death-due-pharmacy-compounding-error-reinforces-need-safety-focus
Compounding pharmacies prepare medicines for patients that a…
-
psnet.ahrq.gov/node/45371/psn-pdf
April 24, 2017 - Patient safety and workplace bullying: an integrative
review.
April 24, 2017
Houck NM, Colbert AM. Patient Safety and Workplace Bullying: An Integrative Review. J Nurs Care Qual.
2017;32(2):164-171. doi:10.1097/NCQ.0000000000000209.
https://psnet.ahrq.gov/issue/patient-safety-and-workplace-bullying-integrative-rev…
-
psnet.ahrq.gov/node/47581/psn-pdf
January 09, 2019 - Patient safety in inpatient psychiatry: a remaining frontier
for health policy.
January 9, 2019
Shields MC, Stewart MT, Delaney KR. Patient Safety In Inpatient Psychiatry: A Remaining Frontier For
Health Policy. Health Aff (Millwood). 2018;37(11):1853-1861. doi:10.1377/hlthaff.2018.0718.
https://psnet.ahrq.gov/iss…
-
psnet.ahrq.gov/node/46447/psn-pdf
September 27, 2017 - Creating highly reliable accountable care organizations.
September 27, 2017
Vogus TJ, Singer SJ. Creating Highly Reliable Accountable Care Organizations. Med Care Res Rev.
2016;73(6):660-672.
https://psnet.ahrq.gov/issue/creating-highly-reliable-accountable-care-organizations
High reliability is a goal throughout …
-
psnet.ahrq.gov/node/854255/psn-pdf
October 04, 2023 - Empowering telemetry technicians and enhancing
communication to improve in-hospital cardiac arrest
survival.
October 4, 2023
McCoy C, Keshvani N, Warsi M, et al. Empowering telemetry technicians and enhancing communication to
improve in-hospital cardiac arrest survival. BMJ Open Qual. 2023;12(3):e002220. doi:10.11…
-
psnet.ahrq.gov/node/34777/psn-pdf
February 16, 2011 - Systems errors versus physicians' errors: finding the
balance in medical education.
February 16, 2011
Casarett D, Helms C. Systems errors versus physicians' errors: finding the balance in medical education.
Acad Med. 1999;74(1):19-22.
https://psnet.ahrq.gov/issue/systems-errors-versus-physicians-errors-finding-bal…
-
psnet.ahrq.gov/node/46129/psn-pdf
September 28, 2017 - Missed diagnosis of cardiovascular disease in outpatient
general medicine: insights from malpractice claims data.
September 28, 2017
Quinn GR, Ranum D, Song E, et al. Missed Diagnosis of Cardiovascular Disease in Outpatient General
Medicine: Insights from Malpractice Claims Data. Jt Comm J Qual Patient Saf. 2017;43…
-
psnet.ahrq.gov/node/854826/psn-pdf
October 25, 2023 - Observing sources of system resilience using in situ
alarm simulations.
October 25, 2023
McLoone M, McNamara M, Jennings MA, et al. Observing sources of system resilience using in situ alarm
simulations. J Hosp Med. 2023;18(11):994-998. doi:10.1002/jhm.13217.
https://psnet.ahrq.gov/issue/observing-sources-system-r…
-
psnet.ahrq.gov/node/46815/psn-pdf
April 29, 2018 - Designing and evaluating an automated system for real-
time medication administration error detection in a
neonatal intensive care unit.
April 29, 2018
Ni Y, Lingren T, Hall ES, et al. Designing and evaluating an automated system for real-time medication
administration error detection in a neonatal intensive care …
-
psnet.ahrq.gov/node/45745/psn-pdf
August 02, 2017 - Emergency diagnosis of cancer and previous general
practice consultations: insights from linked patient
survey data.
August 2, 2017
Abel GA, Mendonca SC, McPhail S, et al. Emergency diagnosis of cancer and previous general practice
consultations: insights from linked patient survey data. Br J Gen Pract. 2017;67(65…
-
psnet.ahrq.gov/node/854821/psn-pdf
October 25, 2023 - Factors determining safety culture in hospitals: a scoping
review.
October 25, 2023
Carvalho REFL de, Bates DW, Syrowatka A, et al. Factors determining safety culture in hospitals: a
scoping review. BMJ Open Qual. 2023;12(4):e002310. doi:10.1136/bmjoq-2023-002310.
https://psnet.ahrq.gov/issue/factors-determining-s…
-
psnet.ahrq.gov/node/866955/psn-pdf
October 16, 2024 - Adverse diagnostic events in hospitalised patients: a
single-centre, retrospective cohort study.
October 16, 2024
Dalal AK, Plombon S, Konieczny K, et al. Adverse diagnostic events in hospitalised patients: a single-
centre, retrospective cohort study. BMJ Qual Saf. 2024;Epub Oct 1. doi:10.1136/bmjqs-2024-017183.
…
-
psnet.ahrq.gov/node/46474/psn-pdf
November 08, 2017 - Clearing the Error: Using Public Deliberation to Define
Patient Roles as Partners in the Diagnostic Process.
November 8, 2017
St. Paul, MN: Society to Improve Diagnosis in Medicine, Maxwell School of Citizenship and Public Affairs at
Syracuse University, and Jefferson Center; 2017.
https://psnet.ahrq.gov/issue/cle…
-
psnet.ahrq.gov/node/45845/psn-pdf
December 19, 2017 - You can't blame the wreck on the train.
December 19, 2017
Potts JR. You can't blame the wreck on the train. Am J Surg. 2017;214(5):974-978.
doi:10.1016/j.amjsurg.2016.11.046.
https://psnet.ahrq.gov/issue/you-cant-blame-wreck-train
Insufficient supervision can limit resident education, which may increase risks to p…
-
psnet.ahrq.gov/node/50569/psn-pdf
October 23, 2019 - Design and implementation of a tool for pharmacists to
register potential errors in prescribed medication.
October 23, 2019
Frid S, Zapico V, Mansilla A, et al. Design and Implementation of a Tool for Pharmacists to Register
Potential Errors in Prescribed Medication. Stud Health Technol Inform. 2019;264:581-585.
d…
-
psnet.ahrq.gov/node/46811/psn-pdf
May 17, 2018 - A surgical procedure grid for safety and operating room
communication in multisite surgery.
May 17, 2018
Insalaco LF, Spiegel JH. A Surgical Procedure Grid for Safety and Operating Room Communication in
Multisite Surgery. JAMA Facial Plast Surg. 2018;20(3):185-186. doi:10.1001/jamafacial.2017.2049.
https://psnet.a…
-
psnet.ahrq.gov/node/836825/psn-pdf
March 30, 2022 - Antibiotic prescribing errors in patients discharged from
the pediatric emergency department.
March 30, 2022
LaScala EC, Monroe AK, Hall GA, et al. Antibiotic prescribing errors in patients discharged from the
pediatric emergency department. Pediatr Emerg Care. 2022;38(1):e387-e392.
doi:10.1097/pec.000000000000229…
-
psnet.ahrq.gov/node/35762/psn-pdf
January 02, 2017 - Using Failure Mode and Effects Analysis for safe
administration of chemotherapy to hospitalized children
with cancer.
January 2, 2017
Robinson DL, Heigham M, Clark J. Using Failure Mode and Effects Analysis for safe administration of
chemotherapy to hospitalized children with cancer. Jt Comm J Qual Patient Saf. 20…
-
psnet.ahrq.gov/node/35332/psn-pdf
September 21, 2005 - Are language barriers associated with serious medical
events in hospitalized pediatric patients?
September 21, 2005
Cohen AL. Are Language Barriers Associated With Serious Medical Events in Hospitalized Pediatric
Patients? Pediatrics. 2005;116(3):575-579. doi:10.1542/peds.2005-0521.
https://psnet.ahrq.gov/issue/ar…
-
psnet.ahrq.gov/node/866728/psn-pdf
September 18, 2024 - ROI for a fall prevention intervention: invest a little, save a
lot.
September 18, 2024
Cooper AS. ROI for a fall prevention intervention: invest a little, save a lot. Nurs Adm Q. 2024;48(3):248-
252. doi:10.1097/naq.0000000000000647.
https://psnet.ahrq.gov/issue/roi-fall-prevention-intervention-invest-little-save…