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psnet.ahrq.gov/issue/errors-thyroid-gland-fine-needle-aspiration
March 28, 2012 - Study
Errors in thyroid gland fine-needle aspiration.
Citation Text:
Raab SS, Vrbin CM, Grzybicki DM, et al. Errors in Thyroid Gland Fine-Needle Aspiration. Am J Clin Pathol. 2007;125(6). doi:10.1309/7rqe37k6439t4pb4.
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psnet.ahrq.gov/issue/national-quality-forum-safe-practice-standard-computerized-physician-order-entry-updating
December 18, 2013 - Review
The National Quality Forum safe practice standard for computerized physician order entry: updating a critical patient safety practice.
Citation Text:
Kilbridge PM, Classen D, Bates DW, et al. The National Quality Forum Safe Practice Standard for Computerized Physician Order Entr…
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psnet.ahrq.gov/issue/contribution-sociotechnical-factors-health-information-technology-related-sentinel-events
September 18, 2024 - Study
The contribution of sociotechnical factors to health information technology–related sentinel events.
Citation Text:
Castro GM, Buczkowski L, Hafner JM. The Contribution of Sociotechnical Factors to Health Information Technology-Related Sentinel Events. Jt Comm J Qual Patient Saf. 2…
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psnet.ahrq.gov/issue/root-cause-analysis-project-medication-safety-course
October 07, 2020 - Commentary
A root cause analysis project in a medication safety course.
Citation Text:
Schafer JJ. A root cause analysis project in a medication safety course. Am J Pharm Educ. 2012;76(6):116. doi:10.5688/ajpe766116.
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psnet.ahrq.gov/issue/best-practice-protocols-preventing-adverse-drug-events
January 18, 2011 - Commentary
Best-practice protocols: preventing adverse drug events.
Citation Text:
Weir VL. Best-practice protocols: preventing adverse drug events. Nurs Manage. 2005;36(9):24-30.
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psnet.ahrq.gov/issue/characteristics-quality-and-patient-safety-curricula-major-teaching-hospitals
February 16, 2011 - Study
Characteristics of quality and patient safety curricula in major teaching hospitals.
Citation Text:
Pingleton SK, Davis DA, Dickler RM. Characteristics of quality and patient safety curricula in major teaching hospitals. Am J Med Qual. 2010;25(4):305-11. doi:10.1177/1062860610367…
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psnet.ahrq.gov/issue/development-checklist-documenting-team-and-collaborative-behaviors-during-multidisciplinary
November 08, 2012 - Study
Development of a checklist for documenting team and collaborative behaviors during multidisciplinary bedside rounds.
Citation Text:
Henneman EA, Kleppel R, Hinchey KT. Development of a checklist for documenting team and collaborative behaviors during multidisciplinary bedside r…
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psnet.ahrq.gov/issue/preventing-patient-harms-through-systems-care
February 27, 2014 - Study
Preventing patient harms through systems of care.
Citation Text:
Pronovost P, Bo-Linn GW. Preventing patient harms through systems of care. JAMA. 2012;308(8):769-70. doi:10.1001/jama.2012.9537.
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psnet.ahrq.gov/issue/primary-medication-non-adherence-analysis-195930-electronic-prescriptions
July 27, 2016 - Study
Primary medication non-adherence: analysis of 195,930 electronic prescriptions.
Citation Text:
Fischer MA, Stedman MR, Lii J, et al. Primary medication non-adherence: analysis of 195,930 electronic prescriptions. J Gen Intern Med. 2010;25(4):284-90. doi:10.1007/s11606-010-1253-9.…
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psnet.ahrq.gov/issue/mitigating-error-vulnerability-transition-care-through-use-health-it-applications
January 23, 2019 - Commentary
Mitigating error vulnerability at the transition of care through the use of health IT applications.
Citation Text:
Cortelyou-Ward K, Swain A, Yeung T. Mitigating Error Vulnerability at the Transition of Care through the Use of Health IT Applications. J Med Syst. 2012;36(6). d…
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psnet.ahrq.gov/issue/assessing-quality-patient-handoffs-care-transitions
April 24, 2013 - Study
Assessing the quality of patient handoffs at care transitions.
Citation Text:
Manser T, Foster S, Gisin S, et al. Assessing the quality of patient handoffs at care transitions. Qual Saf Health Care. 2010;19(6):e44. doi:10.1136/qshc.2009.038430.
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psnet.ahrq.gov/issue/journal-reporting-medical-errors-wisdom-solomon-bravery-achilles-and-foolishness-pan
April 24, 2018 - Review
Journal reporting of medical errors: the wisdom of Solomon, the bravery of Achilles, and the foolishness of Pan.
Citation Text:
Murphy JG, Stee LA, McEvoy MT, et al. Journal reporting of medical errors: the wisdom of Solomon, the bravery of Achilles, and the foolishness of Pan. Ch…
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psnet.ahrq.gov/issue/informatics-confronts-drug-drug-interactions
February 18, 2011 - Review
Informatics confronts drug–drug interactions.
Citation Text:
Percha B, Altman RB. Informatics confronts drug-drug interactions. Trends Pharmacol Sci. 2013;34(3):178-84. doi:10.1016/j.tips.2013.01.006.
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psnet.ahrq.gov/issue/labeling-solutions-and-medications-sterile-procedural-settings
July 13, 2016 - Commentary
Labeling solutions and medications in sterile procedural settings.
Citation Text:
Sheridan DJ. Labeling solutions and medications in sterile procedural settings. Jt Comm J Qual Patient Saf. 2006;32(5):276-82.
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psnet.ahrq.gov/issue/medication-errors-and-patient-complications-continuous-renal-replacement-therapy
June 25, 2009 - Study
Medication errors and patient complications with continuous renal replacement therapy.
Citation Text:
Barletta JF, Barletta G-M, Brophy PD, et al. Medication errors and patient complications with continuous renal replacement therapy. Pediatr Nephrol. 2006;21(6):842-5.
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psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-trade-offs
November 04, 2020 - Commentary
Scandal as a sentinel event—recognizing hidden cost–quality trade-offs.
Citation Text:
Bloche G. Scandal as a Sentinel Event--Recognizing Hidden Cost-Quality Trade-offs. N Engl J Med. 2016;374(11):1001-3. doi:10.1056/NEJMp1502629.
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psnet.ahrq.gov/issue/preparing-challenging-medications-barcode-scanning
October 19, 2022 - Commentary
Preparing challenging medications for barcode scanning.
Citation Text:
Waxlax TJ. Preparing challenging medications for barcode scanning. Am J Health Syst Pharm. 2015;72(13):1089-90. doi:10.2146/ajhp140454.
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psnet.ahrq.gov/issue/medication-reconciliation-rural-trauma-population
April 24, 2018 - Study
Medication reconciliation in a rural trauma population.
Citation Text:
Miller L, Miller S, Balon J, et al. Medication reconciliation in a rural trauma population. Ann Emerg Med. 2008;52(5):483-91. doi:10.1016/j.annemergmed.2008.03.021.
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psnet.ahrq.gov/issue/trainees-voice-recognising-importance-preoperative-briefings-surgical-trainees
October 09, 2019 - Commentary
The trainee's voice: recognising the importance of preoperative briefings for surgical trainees.
Citation Text:
Bethune R, Blencowe NS. The trainee's voice: recognising the importance of preoperative briefings for surgical trainees. J Perioper Pract. 2014;24(3):56-58.
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psnet.ahrq.gov/issue/testing-and-labeling-medical-devices-safety-magnetic-resonance-mr-environment
March 12, 2019 - Book/Report
Testing and Labeling Medical Devices for Safety in the Magnetic Resonance (MR) Environment.
Citation Text:
Testing and Labeling Medical Devices for Safety in the Magnetic Resonance (MR) Environment. Silver Spring, MD: US Department of Health and Human Services, Food and Drug …