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psnet.ahrq.gov/issue/how-discrimination-health-care-affects-older-americans-and-what-health-systems-and-providers
February 28, 2024 - Book/Report
How Discrimination in Health Care Affects Older Americans, and What Health Systems and Providers Can Do.
Citation Text:
How Discrimination in Health Care Affects Older Americans, and What Health Systems and Providers Can Do. Doty MM, Horstman C, Shah A et al. Issue Brief. New…
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psnet.ahrq.gov/issue/action-planning-tool-ahrq-surveys-patient-safety-culture
February 12, 2019 - Toolkit
Action Planning Tool for the AHRQ Surveys on Patient Safety Culture.
Citation Text:
Action Planning Tool for the AHRQ Surveys on Patient Safety Culture. Yount N, Edelman S, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication …
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psnet.ahrq.gov/issue/introduction-discharge-plan-reduce-adverse-events-within-72-hours-discharge-icu
September 16, 2020 - Study
Introduction of discharge plan to reduce adverse events within 72 hours of discharge from the ICU.
Citation Text:
Williams TA, Leslie GD, Elliott N, et al. Introduction of discharge plan to reduce adverse events within 72 hours of discharge from the ICU. J Nurs Care Qual. 2010;25…
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psnet.ahrq.gov/issue/systematic-review-human-factors-and-ergonomics-hfe-based-healthcare-system-redesign-quality
February 13, 2014 - Review
A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety.
Citation Text:
Xie A, Carayon P. A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and pa…
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psnet.ahrq.gov/issue/wakewings-journey-creating-patient-safety-program
September 23, 2020 - Commentary
The WakeWings journey: creating a patient safety program.
Citation Text:
Mills E. The WakeWings Journey: Creating a Patient Safety Program. AORN J. 2016;103(6):636-9. doi:10.1016/j.aorn.2016.04.004.
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psnet.ahrq.gov/issue/patient-safety-and-quality-care
April 01, 2020 - Commentary
Patient safety and quality care.
Citation Text:
Nelson K. Patient safety and quality care. Clin Dermatol. 2014;32(4):542-4. doi:10.1016/j.clindermatol.2013.12.001.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
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psnet.ahrq.gov/issue/influence-tall-man-lettering-errors-visual-perception-recognition-written-drug-names
December 19, 2017 - Study
The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names.
Citation Text:
Darker IT, Gerret D, Filik R, et al. The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names. Ergono…
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psnet.ahrq.gov/issue/reducing-disruptive-effects-interruption-cognitive-framework-analysing-costs-and-benefits
September 11, 2013 - Commentary
Reducing the disruptive effects of interruption: a cognitive framework for analysing the costs and benefits of intervention strategies.
Citation Text:
Boehm-Davis DA, Remington R. Reducing the disruptive effects of interruption: a cognitive framework for analysing the costs an…
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psnet.ahrq.gov/issue/evaluation-collaborative-safety-focused-nurse-pharmacist-intervention-improving-accuracy
April 28, 2010 - Study
An evaluation of a collaborative, safety focused, nurse–pharmacist intervention for improving the accuracy of the medication history.
Citation Text:
Henneman EA, Tessier EG, Nathanson BH, et al. An evaluation of a collaborative, safety focused, nurse-pharmacist intervention for imp…
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psnet.ahrq.gov/issue/root-cause-analysis-cases-involving-diagnosis
August 28, 2019 - Commentary
Root cause analysis of cases involving diagnosis.
Citation Text:
Graber ML, Castro GM, Danforth M, et al. Root cause analysis of cases involving diagnosis. Diagnosis (Berl). 2024;11(4):353-368. doi:10.1515/dx-2024-0102.
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psnet.ahrq.gov/issue/how-can-we-make-diagnosis-safer
April 12, 2014 - Commentary
How can we make diagnosis safer?
Citation Text:
Schiff G, Leape L. Commentary: how can we make diagnosis safer? Acad Med. 2012;87(2):135-138. doi:10.1097/ACM.0b013e31823f711c.
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psnet.ahrq.gov/issue/guide-patient-and-family-engagement-hospital-quality-and-safety
December 24, 2008 - Multi-use Website
Guide to Patient and Family Engagement in Hospital Quality and Safety.
Citation Text:
Guide to Patient and Family Engagement in Hospital Quality and Safety. Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
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psnet.ahrq.gov/issue/pediatric-diagnostic-safety-state-science-and-future-directions
August 16, 2023 - Book/Report
Pediatric Diagnostic Safety: State of the Science and Future Directions.
Citation Text:
Pediatric Diagnostic Safety: State of the Science and Future Directions. Grubenhoff JA, Cifra CL, Marshall T, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 20…
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psnet.ahrq.gov/issue/american-college-endocrinology-and-american-association-clinical-endocrinologists-position
August 20, 2018 - Commentary
American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology.
Citation Text:
Bates DW, Clark NG, Cook RI, et al. American College of Endocrinology and Amer…
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psnet.ahrq.gov/node/49868/psn-pdf
July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With
Dementia
July 2, 2019
Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
The Case
An 86-year-old man with neurode…
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psnet.ahrq.gov/node/866847/psn-pdf
September 25, 2024 - In Conversation with Carole Stockmeier about Zero Harm:
Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 25, 2024
Stockmeier CA, Mossburg S, Lee M. In Conversation with Carole Stockmeier about Zero Harm: Striving to
Reduce Preventable Harms – Point, Counterpoint, and Are…
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psnet.ahrq.gov/node/49439/psn-pdf
March 01, 2004 - Lethal Cap
March 1, 2004
Schillinger D. Lethal Cap. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/lethal-cap
The Case
A 9-month-old child was seen by her pediatrician for a fever and decreased appetite. She was found to
have otitis media and was prescribed amoxicillin. The doctor gave the first dose to th…
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psnet.ahrq.gov/node/33565/psn-pdf
September 01, 2024 - Healthcare-associated Infections
June 15, 2024
Healthcare - Associated Infections. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/health-care-associated-infections
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice …
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psnet.ahrq.gov/issue/making-residents-part-safety-culture-improving-error-reporting-and-reducing-harms
April 24, 2018 - Commentary
Making residents part of the safety culture: improving error reporting and reducing harms.
Citation Text:
Fox MD, Bump GM, Butler GA, et al. Making Residents Part of the Safety Culture: Improving Error Reporting and Reducing Harms. J Patient Saf. 2021;17(5):e373-e378. doi:10.1…
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psnet.ahrq.gov/issue/using-six-sigma-reduce-medication-errors-home-delivery-pharmacy-service
November 18, 2015 - Study
Using Six Sigma to reduce medication errors in a home-delivery pharmacy service.
Citation Text:
Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24.
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