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psnet.ahrq.gov/issue/lessons-learned-about-human-fallibility-system-design-and-justice-aftermath-fatal-medication
August 17, 2022 - Webinar
Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error.
Citation Text:
Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error. Institute for Safe Medication Practic…
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psnet.ahrq.gov/issue/covid-19-reminder-reason
October 24, 2018 - Commentary
COVID-19 — a reminder to reason
Citation Text:
Zagury-Orly I, Schwartzstein RM. COVID-19 — A Reminder to Reason. N Engl J Med. 2020;383(3):e12. doi:10.1056/nejmp2009405.
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psnet.ahrq.gov/issue/some-doctors-are-ditching-scale-saying-focusing-weight-drives-misdiagnoses
November 01, 2023 - Newspaper/Magazine Article
Some doctors are ditching the scale, saying focusing on weight drives misdiagnoses.
Citation Text:
Some doctors are ditching the scale, saying focusing on weight drives misdiagnoses. O'Neill E. Health Shots. National Public Radio. December 2, 2023.
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psnet.ahrq.gov/issue/poor-medication-history-plus-slow-symptom-onset-delays-diagnosis
October 12, 2022 - Commentary
Poor medication history plus slow symptom onset delays a diagnosis.
Citation Text:
Poor medication history plus slow symptom onset delays a diagnosis. Wilkin T, Hale LS, Claiborne RA. JAAPA. October 2009;22:39-41.
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psnet.ahrq.gov/issue/implementation-patient-safety-initiatives-us-hospitals
December 12, 2014 - Commentary
Implementation of patient safety initiatives in US hospitals.
Citation Text:
McFadden KL, Stock GN, Gowen CR. Implementation of patient safety initiatives in US hospitals. Int J Oper Prod Manag. 2006;26(3):326-347. doi:10.1108/01443570610651052.
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psnet.ahrq.gov/issue/tubing-misconnections-normalization-deviance
December 16, 2015 - Review
Tubing misconnections: normalization of deviance.
Citation Text:
Simmons D, Symes L, Guenter P, et al. Tubing misconnections: normalization of deviance. Nutr Clin Pract. 2011;26(3):286-293. doi:10.1177/0884533611406134.
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psnet.ahrq.gov/issue/tubing-safety-obstetric-setting-preventing-medication-errors
November 04, 2020 - Commentary
Tubing safety in the obstetric setting: preventing medication errors.
Citation Text:
Broussard BS. Tubing safety in the obstetric setting: preventing medication errors. Nurs Womens Health. 2009;13(2):155-158. doi:10.1111/j.1751-486X.2009.01407.x.
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psnet.ahrq.gov/issue/variability-pharmacy-interpretations-physician-prescriptions
September 25, 2008 - Study
Variability in pharmacy interpretations of physician prescriptions.
Citation Text:
Wolf MS, Shekelle PG, Choudhry NK, et al. Variability in pharmacy interpretations of physician prescriptions. Med Care. 2009;47(3):370-373. doi:10.1097/MLR.0b013e31818af91a.
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psnet.ahrq.gov/issue/instrument-readiness-important-link-patient-safety
January 05, 2011 - Commentary
Instrument readiness: an important link to patient safety.
Citation Text:
McNamara SA. Instrument readiness: an important link to patient safety. AORN J. 2011;93(1):160-4. doi:10.1016/j.aorn.2010.09.027.
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psnet.ahrq.gov/issue/randomized-field-study-leadership-walkrounds-based-intervention
May 24, 2016 - Book/Report
A Randomized Field Study of a Leadership WalkRounds-Based Intervention.
Citation Text:
A Randomized Field Study of a Leadership WalkRounds-Based Intervention. Tucker AL, Singer SJ. Cambridge, MA: Harvard Business School; June 25, 2012. HBS Working Paper No. 12-113.
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psnet.ahrq.gov/issue/patient-safety-traditional-and-evolving-nontraditional-office-setting
September 14, 2011 - Commentary
Patient Safety in the Traditional and Evolving Nontraditional Office Setting
Citation Text:
Keats JP, Gambone JC. Patient Safety in the Traditional and Evolving Nontraditional Office Setting. Clin Obstet Gynecol. 2019;62(3):580-593. doi:10.1097/GRF.0000000000000471.
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psnet.ahrq.gov/issue/creating-culture-safety-coaching-clinicians-competence
January 10, 2024 - Commentary
Creating a culture of safety by coaching clinicians to competence.
Citation Text:
Duff B. Creating a culture of safety by coaching clinicians to competence. Nurse Educ Today. 2013;33(10):1108-11. doi:10.1016/j.nedt.2012.05.025.
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psnet.ahrq.gov/issue/embedding-quality-and-safety-otolaryngology-head-and-neck-surgery-education
August 11, 2010 - Commentary
Embedding quality and safety in otolaryngology–head and neck surgery education.
Citation Text:
McCormick ME, Stadler ME, Shah RK. Embedding quality and safety in otolaryngology-head and neck surgery education. Otolaryngol Head Neck Surg. 2015;152(5):778-782. doi:10.1177/019459…
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psnet.ahrq.gov/issue/drug-related-hospital-admissions
September 07, 2016 - Study
Classic
Drug-related hospital admissions.
Citation Text:
Drug-related hospital admissions. Einarson TR
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psnet.ahrq.gov/issue/new-covid-boosters-look-lot-old-ones-doctors-worry-could-lead-errors
April 26, 2023 - Newspaper/Magazine Article
New Covid boosters look a lot like the old ones. Doctors worry that could lead to errors.
Citation Text:
New Covid boosters look a lot like the old ones. Doctors worry that could lead to errors. Lovelace Jr, B. NBC News. September 7, 2022.
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psnet.ahrq.gov/issue/ems-crews-brought-patients-hospital-misplaced-breathing-tubes-none-them-survived
November 20, 2019 - Newspaper/Magazine Article
EMS crews brought patients to the hospital with misplaced breathing tubes. None of them survived
Citation Text:
EMS crews brought patients to the hospital with misplaced breathing tubes. None of them survived Arditi L. Peoples Public Radio. December 3, 2019.
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psnet.ahrq.gov/issue/insulin-dosing-error-patient-severe-hyperkalemia
May 06, 2020 - Commentary
Insulin dosing error in a patient with severe hyperkalemia.
Citation Text:
Hewitt B, Barnard C, Bilimoria KY. Insulin Dosing Error in a Patient With Severe Hyperkalemia. JAMA. 2017;318(24):2485-2486. doi:10.1001/jama.2017.7964.
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psnet.ahrq.gov/issue/enhanced-time-out-improved-communication-process
October 19, 2022 - Commentary
Enhanced time out: an improved communication process.
Citation Text:
Nelson PE. Enhanced Time Out: An Improved Communication Process. AORN J. 2017;105(6):564-570. doi:10.1016/j.aorn.2017.03.014.
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psnet.ahrq.gov/issue/technology-education-and-safety-3
October 11, 2023 - Special or Theme Issue
Technology, Education and Safety.
Citation Text:
Technology, Education and Safety. Harbell MW, ed. Curr Opin Anaesthesiol. 2024;37(6):666-742.
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psnet.ahrq.gov/issue/error-disclosure-pathology-and-laboratory-medicine-review-literature
July 28, 2021 - Review
Error disclosure in pathology and laboratory medicine: a review of the literature.
Citation Text:
Perkins IU. Error Disclosure in Pathology and Laboratory Medicine: A Review of the Literature. AMA J Ethics. 2016;18(8):809-16. doi:10.1001/journalofethics.2016.18.8.nlit1-1608.
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