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  1. Effect of barcode-assisted medication administration on emergency department medication errors. | PSNet

    psnet.ahrq.gov/issue/effect-barcode-assisted-medication-administration-emergency-department-medication-errors
    May 19, 2014 - Study Effect of barcode-assisted medication administration on emergency department medication errors. Citation Text: Bonkowski J, Carnes C, Melucci J, et al. Effect of barcode-assisted medication administration on emergency department medication errors. Acad Emerg Med. 2013;20(8):801-6.…

  2. 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…

  3. 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…

  4. Infection prevention in the operating room anesthesia work area. | PSNet

    psnet.ahrq.gov/issue/infection-prevention-operating-room-anesthesia-work-area
    March 02, 2014 - Commentary Infection prevention in the operating room anesthesia work area. Citation Text: Munoz-Price S, Bowdle A, Johnston L, et al. Infection prevention in the operating room anesthesia work area. Infect Control Hosp Epidemiol. 2018:1-17. doi:10.1017/ice.2018.303. Copy Citation …

  5. Delineation of risk through the exploration of a culture of safety in community home health. | PSNet

    psnet.ahrq.gov/issue/delineation-risk-through-exploration-culture-safety-community-home-health
    December 04, 2016 - Study Delineation of risk through the exploration of a culture of safety in community home health. Citation Text: Stevenson L, McRae C, Mughal WA. Delineation of Risk Through the Exploration of a Culture of Safety in Community Home Health. Home Health Care Manag Pract. 2007;19(6). doi:…

  6. Eradicating central line–associated bloodstream infections statewide: the Hawaii experience. | PSNet

    psnet.ahrq.gov/issue/eradicating-central-line-associated-bloodstream-infections-statewide-hawaii-experience
    January 15, 2014 - Study Eradicating central line–associated bloodstream infections statewide: the Hawaii experience. Citation Text: Lin D, Weeks K, Bauer L, et al. Eradicating Central Line–Associated Bloodstream Infections Statewide. American Journal of Medical Quality. 2011;27(2). doi:10.1177/106286061…

  7. 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…

  8. Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit. | PSNet

    psnet.ahrq.gov/issue/improving-teamwork-impact-structured-interdisciplinary-rounds-medical-teaching-unit
    December 21, 2014 - Study Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit. Citation Text: O'Leary KJ, Wayne DB, Haviley C, et al. Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit. J Gen Intern Med. 2010;25(8):826-32. do…

  9. Should patients get direct access to their laboratory test results?: An answer with many questions. | PSNet

    psnet.ahrq.gov/issue/should-patients-get-direct-access-their-laboratory-test-results-answer-many-questions
    November 13, 2024 - Commentary Should patients get direct access to their laboratory test results?: An answer with many questions. Citation Text: Giardina TD, Singh H. Should patients get direct access to their laboratory test results? An answer with many questions. JAMA. 2011;306(22):2502-2503. doi:10.10…

  10. Prescribing errors in children: why they happen and how to prevent them. | PSNet

    psnet.ahrq.gov/issue/prescribing-errors-children-why-they-happen-and-how-prevent-them
    December 13, 2017 - Newspaper/Magazine Article Prescribing errors in children: why they happen and how to prevent them. Citation Text: Conn R, Fox A, Carrington A, et al. Prescribing errors in children: why they happen and how to prevent them. Pharmaceutical Journal. 2023;310:7973. doi:10.1211/pj.2023.1.184…

  11. Development and implementation of a pediatric patient safety program. | PSNet

    psnet.ahrq.gov/issue/development-and-implementation-pediatric-patient-safety-program
    September 27, 2010 - Commentary Development and implementation of a pediatric patient safety program. Citation Text: Alton M, Frush K, Brandon D, et al. DEVELOPMENT AND IMPLEMENTATION OF A PEDIATRIC PATIENT SAFETY PROGRAM. Adv Neonatal Care. 2006;6(3):104-111. doi:10.1016/j.adnc.2006.02.003. Copy Citatio…

  12. Medical error, incident investigation and the second victim: doing better but feeling worse? | PSNet

    psnet.ahrq.gov/issue/medical-error-incident-investigation-and-second-victim-doing-better-feeling-worse
    July 29, 2020 - Commentary Medical error, incident investigation and the second victim: doing better but feeling worse? Citation Text: Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf. 2012;21(4):267-70. doi:10.1136/bmjqs-20…

  13. Assigning responsibility to close the loop on radiology test results. | PSNet

    psnet.ahrq.gov/issue/assigning-responsibility-close-loop-radiology-test-results
    April 03, 2024 - Review Assigning responsibility to close the loop on radiology test results. Citation Text: Kwan JL, Singh H. Assigning responsibility to close the loop on radiology test results. Diagnosis (Berl). 2017;4(3):173-177. doi:10.1515/dx-2017-0019. Copy Citation Format: DOI Googl…

  14. The contribution of nurses to incident disclosure: a narrative review. | PSNet

    psnet.ahrq.gov/issue/contribution-nurses-incident-disclosure-narrative-review
    March 15, 2016 - Review The contribution of nurses to incident disclosure: a narrative review. Citation Text: Harrison R, Birks Y, Hall J, et al. The contribution of nurses to incident disclosure: a narrative review. Int J Nurs Stud. 2014;51(2):334-45. doi:10.1016/j.ijnurstu.2013.07.001. Copy Citatio…

  15. Effectiveness of random and focused review in detecting surgical pathology error. | PSNet

    psnet.ahrq.gov/issue/effectiveness-random-and-focused-review-detecting-surgical-pathology-error
    August 04, 2021 - Study Effectiveness of random and focused review in detecting surgical pathology error. Citation Text: Raab SS, Grzybicki DM, Mahood LK, et al. Effectiveness of random and focused review in detecting surgical pathology error. Am J Clin Pathol. 2008;130(6):905-12. doi:10.1309/AJCPPIA5…

  16. Findings from the ISMP Medication Safety Self-Assessment for hospitals. | PSNet

    psnet.ahrq.gov/issue/findings-ismp-medication-safety-self-assessment-hospitals
    September 26, 2017 - Study Findings from the ISMP Medication Safety Self-Assessment for hospitals. Citation Text: Smetzer JL, Vaida AJ, Cohen MR, et al. Findings from the ISMP Medication Safety Self-Assessment for hospitals. Jt Comm J Qual Patient Saf. 2003;29(11):586-597. Copy Citation Format: …

  17. More to teamwork than knowledge, skill and attitude. | PSNet

    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. Copy Citation Format: DOI Google Sc…

  18. Learning from defects to enhance morbidity and mortality conferences. | PSNet

    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. Copy Citation …

  19. Increasing physician reporting of diagnostic learning opportunities. | PSNet

    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. Copy Citation Format: …

  20. Association of resident fatigue and distress with perceived medical errors. | PSNet

    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. Copy Citation …
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