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Evidence Brief: Implementation of High Reliability Organization Principles. | PSNet

psnet.ahrq.gov/issue/evidence-brief-implementation-high-reliability-organization-principles

November 11, 2020 - Book/Report Evidence Brief: Implementation of High Reliability Organization Principles. Citation Text: Evidence Brief: Implementation of High Reliability Organization Principles. Veazie S, Peterson K, Bourne D. Washington DC: United States Department of Veterans Affairs; May 2019. …

Automated drug dispensing system reduces medication errors in an intensive care setting. | PSNet

psnet.ahrq.gov/issue/automated-drug-dispensing-system-reduces-medication-errors-intensive-care-setting

April 08, 2009 - Study Automated drug dispensing system reduces medication errors in an intensive care setting. Citation Text: Chapuis C, Roustit M, Bal G, et al. Automated drug dispensing system reduces medication errors in an intensive care setting. Crit Care Med. 2010;38(12):2275-2281. doi:10.1097/C…

Errors during the preparation of drug infusions: a randomized controlled trial. | PSNet

psnet.ahrq.gov/issue/errors-during-preparation-drug-infusions-randomized-controlled-trial

March 02, 2011 - Study Errors during the preparation of drug infusions: a randomized controlled trial. Citation Text: Adapa RM, Mani V, Murray LJ, et al. Errors during the preparation of drug infusions: a randomized controlled trial. Br J Anaesth. 2012;109(5):729-34. doi:10.1093/bja/aes257. Copy Cita…

VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement. | PSNet

psnet.ahrq.gov/issue/va-health-care-selected-credentialing-requirements-seven-medical-facilities-met-aspect

July 05, 2006 - Government Resource VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement. Citation Text: VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileg…

Unmet Needs: Teaching Physicians to Provide Safe Patient Care. | PSNet

psnet.ahrq.gov/issue/unmet-needs-teaching-physicians-provide-safe-patient-care

November 07, 2012 - Book/Report Classic Unmet Needs: Teaching Physicians to Provide Safe Patient Care. Citation Text: Unmet Needs: Teaching Physicians to Provide Safe Patient Care. Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; March 2010. Copy Cita…

The Economics of Patient Safety in Primary and Ambulatory Care: Flying Blind. | PSNet

psnet.ahrq.gov/issue/economics-patient-safety-primary-and-ambulatory-care-flying-blind

April 12, 2017 - Book/Report Emerging Classic The Economics of Patient Safety in Primary and Ambulatory Care: Flying Blind. Citation Text: The Economics of Patient Safety in Primary and Ambulatory Care: Flying Blind. Slawomirski L, Auraaen A, Klazinga N. Paris, France: Organisat…

The medication kit conundrum: considerations to enhance safety and efficiency. | PSNet

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June 07, 2017 - Commentary The medication kit conundrum: considerations to enhance safety and efficiency. Citation Text: Arthur KJ, Fuller J, Dossett HA, et al. The medication kit conundrum: considerations to enhance safety and efficiency. Am J Health Syst Pharm. 2024;Epub Sep 4. doi:10.1093/ajhp/zxae23…

Set Phasers on Stun: And Other True Tales of Design, Technology, and Human Error, Second Edition. | PSNet

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May 30, 2019 - Book/Report Classic Set Phasers on Stun: And Other True Tales of Design, Technology, and Human Error, Second Edition. Citation Text: Set Phasers on Stun: And Other True Tales of Design, Technology, and Human Error, Second Edition. Casey SM. Santa Barbara, CA: Ae…

Quality of Care in Cranial Implant Surgeries at James A. Haley VA Medical Center, Tampa, Florida. | PSNet

psnet.ahrq.gov/issue/quality-care-cranial-implant-surgeries-james-haley-va-medical-center-tampa-florida

June 13, 2012 - Government Resource Quality of Care in Cranial Implant Surgeries at James A. Haley VA Medical Center, Tampa, Florida. Citation Text: Quality of Care in Cranial Implant Surgeries at James A. Haley VA Medical Center, Tampa, Florida. Washington, DC: VA Office of Inspector General; April 1…

Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy. | PSNet

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April 28, 2021 - Book/Report Classic Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy. Citation Text: Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy. Wu HW, Nishimi RY, Page-Lopez CM, et …

AHRQ Health Information Technology Research: 2018 Year in Review. | PSNet

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May 07, 2014 - Government Resource AHRQ Health Information Technology Research: 2018 Year in Review. Citation Text: AHRQ Health Information Technology Research: 2018 Year in Review. AHRQ Health Information Technology Research: 2018 Year in Review. (Prepared by John Snow, Inc. Under Contract No. HHSN316…

Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections. | PSNet

psnet.ahrq.gov/issue/health-care-associated-infections-hospitals-leadership-needed-hhs-prioritize-prevention

October 15, 2008 - Book/Report Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections. Citation Text: Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices a…

Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge. | PSNet

psnet.ahrq.gov/issue/medication-reconciliation-acute-care-ensuring-accurate-drug-regimen-admission-and-discharge

October 28, 2020 - Commentary Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge. Citation Text: Rodehaver C, Fearing D. Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge. Jt Comm J Qual Patient Saf. 2005…

Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. | PSNet

psnet.ahrq.gov/issue/indian-health-service-actions-needed-improve-use-data-adverse-events

September 07, 2016 - Book/Report Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. Citation Text: Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. Washington, DC: United States Government Accounting Office; July 10, 2023. Publication GAO-23-1…

Bringing change-of-shift report to the bedside: a patient- and family-centered approach. | PSNet

psnet.ahrq.gov/issue/bringing-change-shift-report-bedside-patient-and-family-centered-approach

August 18, 2021 - Commentary Bringing change-of-shift report to the bedside: a patient- and family-centered approach. Citation Text: Griffin T. Bringing change-of-shift report to the bedside: a patient- and family-centered approach. J Perinat Neonatal Nurs. 2010;24(4):348-355. doi:10.1097/JPN.0b013e3181f8…

Using a quantitative risk register to promote learning from a patient safety reporting system. | PSNet

psnet.ahrq.gov/issue/using-quantitative-risk-register-promote-learning-patient-safety-reporting-system

September 24, 2010 - Study Using a quantitative risk register to promote learning from a patient safety reporting system. Citation Text: Mansfield JG, Caplan RA, Campos JS, et al. Using a quantitative risk register to promote learning from a patient safety reporting system. Jt Comm J Qual Patient Saf. 2015;4…

Ethical duty of health care systems to address interfacility medical error discovery. | PSNet

psnet.ahrq.gov/issue/ethical-duty-health-care-systems-address-interfacility-medical-error-discovery

September 11, 2019 - Commentary Ethical duty of health care systems to address interfacility medical error discovery. Citation Text: Antunez AG, Shuman AG, Jagsi R, et al. Ethical Duty of Health Care Systems to Address Interfacility Medical Error Discovery. J Am Coll Surg. 2018;227(5):543-547. doi:10.1016/j.…

The development of the National Reporting and Learning System in England and Wales, 2001-2005. | PSNet

psnet.ahrq.gov/issue/development-national-reporting-and-learning-system-england-and-wales-2001-2005

September 14, 2022 - Commentary The development of the National Reporting and Learning System in England and Wales, 2001-2005. Citation Text: Williams SK, Osborn SS. The development of the National Reporting and Learning System in England and Wales, 2001–2005. Med J Aust. 2019;184(S10) (S10):s65-s68. doi:1…

The Report of the Manitoba Pediatric Cardiac Surgery Inquest: An Inquiry into Twelve Deaths at the Winnipeg Health Sciences Center in 1994. | PSNet

psnet.ahrq.gov/issue/report-manitoba-pediatric-cardiac-surgery-inquest-inquiry-twelve-deaths-winnipeg-health

October 05, 2022 - Book/Report The Report of the Manitoba Pediatric Cardiac Surgery Inquest: An Inquiry into Twelve Deaths at the Winnipeg Health Sciences Center in 1994. Citation Text: The Report of the Manitoba Pediatric Cardiac Surgery Inquest: An Inquiry into Twelve Deaths at the Winnipeg Health Scienc…

Fatal misadministration of IV vincristine. | PSNet

psnet.ahrq.gov/issue/fatal-misadministration-iv-vincristine

December 21, 2016 - Newspaper/Magazine Article Fatal misadministration of IV vincristine. Citation Text: Fatal misadministration of IV vincristine. ISMP Medication Safety Alert! Acute care edition. December 1, 2005 Copy Citation Save Save to your library Print Download PDF …

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