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psnet.ahrq.gov/issue/managing-clinical-failure-complex-adaptive-system-perspective
August 13, 2014 - Study
Managing clinical failure: a complex adaptive system perspective.
Citation Text:
Matthews JI, Thomas PT. Managing clinical failure: a complex adaptive system perspective. Int J Health Care Qual Assur. 2007;20(3):184-194. doi:10.1108/09526860710743336.
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psnet.ahrq.gov/issue/improving-communication-diagnostic-uncertainty-families-hospitalized-children
December 23, 2020 - Study
Improving communication of diagnostic uncertainty to families of hospitalized children.
Citation Text:
Young EE, Kane J, Timmons K, et al. Improving communication of diagnostic uncertainty to families of hospitalized children. Diagnosis (Berl). 2024;11(2):186-191. doi:10.1515/dx-20…
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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…
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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…
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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…
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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…
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psnet.ahrq.gov/issue/evidence-based-red-cell-transfusion-critically-ill-quality-improvement-using-computerized
February 15, 2017 - Study
Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry.
Citation Text:
Rana R, Afessa B, Keegan MT, et al. Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician …
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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…
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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…
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psnet.ahrq.gov/issue/framework-encouraging-patient-engagement-medical-decision-making
September 17, 2010 - Commentary
A framework for encouraging patient engagement in medical decision making.
Citation Text:
Holzmueller CG, Wu AW, Pronovost P. A framework for encouraging patient engagement in medical decision making. J Patient Saf. 2012;8(4):161-164. doi:10.1097/PTS.0b013e318267c56e.
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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.
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psnet.ahrq.gov/issue/pharmacy-dispensing-errors-claims-study-emphasizes-need-systematic-vigilance
April 06, 2022 - Newspaper/Magazine Article
Pharmacy dispensing errors: claims study emphasizes need for systematic vigilance.
Citation Text:
Pharmacy dispensing errors: claims study emphasizes need for systematic vigilance. Webb J. Drug Topics. March 10, 2015.
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psnet.ahrq.gov/issue/hospital-readmissions-reduction-program-implications-pharmacy
September 23, 2020 - Commentary
Hospital Readmissions Reduction Program: implications for pharmacy.
Citation Text:
Boesen KAG, Leal S, Sheehan VC, et al. Hospital Readmissions Reduction Program: implications for pharmacy. Am J Health Syst Pharm. 2015;72(3):237-44. doi:10.2146/ajhp140177.
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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.
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psnet.ahrq.gov/issue/health-literacy-primary-care-practice
September 06, 2017 - Commentary
Health literacy in primary care practice.
Citation Text:
Hersh L, Salzman B, Snyderman D. Health Literacy in Primary Care Practice. Am Fam Physician. 2015;92(2):118-124.
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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.
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psnet.ahrq.gov/issue/sources-and-types-discrepancies-between-electronic-medical-records-and-actual-outpatient
July 19, 2023 - Study
Sources and types of discrepancies between electronic medical records and actual outpatient medication use.
Citation Text:
Orrico KB. Sources and types of discrepancies between electronic medical records and actual outpatient medication use. J Manag Care Pharm. 2008;14(7):626-631…
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psnet.ahrq.gov/issue/relationship-between-patients-perceptions-team-effectiveness-and-their-care-experience
June 08, 2011 - Study
The relationship between patients' perceptions of team effectiveness and their care experience in the emergency department.
Citation Text:
Kipnis A, Rhodes K, Burchill CN, et al. The relationship between patients' perceptions of team effectiveness and their care experience in the…
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psnet.ahrq.gov/issue/why-patients-need-leaders-introducing-ward-safety-checklist
October 28, 2020 - Commentary
Why patients need leaders: introducing a ward safety checklist.
Citation Text:
Amin Y, Grewcock D, Andrews S, et al. Why patients need leaders: introducing a ward safety checklist. J R Soc Med. 2012;105(9):377-83. doi:10.1258/jrsm.2012.120098.
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psnet.ahrq.gov/issue/factors-associated-disclosure-medical-errors-housestaff
January 27, 2019 - Study
Factors associated with disclosure of medical errors by housestaff.
Citation Text:
Kronman AC, Paasche-Orlow MK, Orlander JD. Factors associated with disclosure of medical errors by housestaff. BMJ Qual Saf. 2011;21(4). doi:10.1136/bmjqs-2011-000084.
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