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  1. Implementing a standardized safe surgery program reduces serious reportable events. | PSNet

    psnet.ahrq.gov/issue/implementing-standardized-safe-surgery-program-reduces-serious-reportable-events
    October 30, 2024 - Study Implementing a standardized safe surgery program reduces serious reportable events. Citation Text: Loftus T, Dahl D, OHare B, et al. Implementing a standardized safe surgery program reduces serious reportable events. J Am Coll Surg. 2015;220(1):12-17.e3. doi:10.1016/j.jamcollsurg.2…

  2. Diagnostic safety: needs assessment and informed curriculum at an academic children's hospital. | PSNet

    psnet.ahrq.gov/issue/diagnostic-safety-needs-assessment-and-informed-curriculum-academic-childrens-hospital
    June 28, 2023 - Study Diagnostic safety: needs assessment and informed curriculum at an academic children's hospital. Citation Text: Congdon M, Rasooly IR, Toto RL, et al. Diagnostic safety: needs assessment and informed curriculum at an academic children's hospital. Pediatr Qual Saf. 2024;9(6):e773. do…

  3. Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009–2014. | PSNet

    psnet.ahrq.gov/issue/opioid-related-inpatient-stays-and-emergency-department-visits-state-2009-2014
    May 11, 2016 - Book/Report Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009–2014. Citation Text: Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009–2014. Weiss AJ, Elixhauser A, Barrett ML, Steiner CA, Bailey MK, O'Malley L. HCUP Statistical Brief…

  4. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing-2019. | PSNet

    psnet.ahrq.gov/issue/ashp-national-survey-pharmacy-practice-hospital-settings-prescribing-and-transcribing-2019
    October 19, 2022 - Study ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing-2019. Citation Text: Pedersen CA, Schneider PJ, Ganio MC, et al. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2019. Am J Health Syst Pharm. 2…

  5. Crossing the Global Quality Chasm: Improving Health Care Worldwide. | PSNet

    psnet.ahrq.gov/issue/crossing-global-quality-chasm-improving-health-care-worldwide
    June 15, 2011 - Book/Report Classic Crossing the Global Quality Chasm: Improving Health Care Worldwide. Citation Text: Crossing the Global Quality Chasm: Improving Health Care Worldwide. Committee on Improving the Quality of Health Care Globally. National Academies of Sciences,…

  6. Preventing Medication Errors: Quality Chasm Series. | PSNet

    psnet.ahrq.gov/issue/preventing-medication-errors-quality-chasm-series
    January 04, 2009 - Book/Report Classic Preventing Medication Errors: Quality Chasm Series. Citation Text: Preventing Medication Errors: Quality Chasm Series. Aspden P, Wolcott J, Bootman JL, et al, eds; Institute of Medicine, Committee on Identifying and Preventing Medication …

  7. Hospitalized patients' attitudes about and participation in error prevention. | PSNet

    psnet.ahrq.gov/issue/hospitalized-patients-attitudes-about-and-participation-error-prevention
    December 22, 2008 - Study Hospitalized patients' attitudes about and participation in error prevention. Citation Text: Waterman AD, Gallagher TH, Garbutt J, et al. Brief report: Hospitalized patients' attitudes about and participation in error prevention. J Gen Intern Med. 2006;21(4):367-70. Copy Citati…

  8. The HOSPITAL score predicts potentially preventable 30-day readmissions in conditions targeted by the Hospital Readmissions Reduction Program. | PSNet

    psnet.ahrq.gov/issue/hospital-score-predicts-potentially-preventable-30-day-readmissions-conditions-targeted
    May 08, 2017 - Study The HOSPITAL score predicts potentially preventable 30-day readmissions in conditions targeted by the Hospital Readmissions Reduction Program. Citation Text: Burke RE, Schnipper JL, Williams M, et al. The HOSPITAL Score Predicts Potentially Preventable 30-Day Readmissions in Condit…

  9. Error rates in breast imaging reports: comparison of automatic speech recognition and dictation transcription. | PSNet

    psnet.ahrq.gov/issue/error-rates-breast-imaging-reports-comparison-automatic-speech-recognition-and-dictation
    December 21, 2022 - Study Error rates in breast imaging reports: comparison of automatic speech recognition and dictation transcription. Citation Text: Basma S, Lord B, Jacks LM, et al. Error rates in breast imaging reports: comparison of automatic speech recognition and dictation transcription. AJR Am J …

  10. Resident attitudes regarding the impact of the 80–duty-hours work standards. | PSNet

    psnet.ahrq.gov/issue/resident-attitudes-regarding-impact-80-duty-hours-work-standards
    August 24, 2015 - Study Resident attitudes regarding the impact of the 80–duty-hours work standards. Citation Text: Zonia SC, 2nd RJLB, Stommel M, et al. Resident attitudes regarding the impact of the 80-duty-hours work standards. J Am Osteopath Assoc. 2005;105(7):307-313. https://www.degruyter.com/docu…

  11. Participation in a system-thinking simulation experience changes adverse event reporting. | PSNet

    psnet.ahrq.gov/issue/participation-system-thinking-simulation-experience-changes-adverse-event-reporting
    July 30, 2014 - Study Participation in a system-thinking simulation experience changes adverse event reporting. Citation Text: Sanko JS, Mckay M. Participation in a system-thinking simulation experience changes adverse event reporting. Simul Healthc. 2020;15(3):167-171. doi:10.1097/sih.0000000000000473.…

  12. Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer. | PSNet

    psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-safe-administration-chemotherapy-hospitalized
    August 08, 2018 - Study Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer. Citation Text: Robinson DL, Heigham M, Clark J. Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer…

  13. Human factors and quality improvement in the emergency department: reducing potential errors in blood collection. | PSNet

    psnet.ahrq.gov/issue/human-factors-and-quality-improvement-emergency-department-reducing-potential-errors-blood
    October 14, 2011 - Study Human factors and quality improvement in the emergency department: reducing potential errors in blood collection. Citation Text: Bashkin O, Caspi S, Swissa A, et al. Human Factors and Quality Improvement in the Emergency Department: Reducing Potential Errors in Blood Collection. J …

  14. Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration. | PSNet

    psnet.ahrq.gov/issue/patient-misidentification-laboratory-medicine-qualitative-analysis-227-root-cause-analysis
    August 28, 2024 - Study Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration. Citation Text: Dunn EJ, Moga PJ. Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis …

  15. Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards. | PSNet

    psnet.ahrq.gov/issue/inpatient-suicide-mental-health-units-veterans-affairs-va-hospitals-avoiding-environmental
    September 05, 2018 - Study Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards. Citation Text: Mills PD, King LA, Watts B, et al. Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards. Gen Hosp Psych…

  16. Complications: acknowledging, managing, and coping with human error. | PSNet

    psnet.ahrq.gov/issue/complications-acknowledging-managing-and-coping-human-error
    March 13, 2024 - Review Complications: acknowledging, managing, and coping with human error. Citation Text: Helo S, Moulton C-AE. Complications: acknowledging, managing, and coping with human error. Transl Androl Urol. 2017;6(4):773-782. doi:10.21037/tau.2017.06.28. Copy Citation Format: DO…

  17. Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets. | PSNet

    psnet.ahrq.gov/issue/identification-and-safe-storage-look-alike-sound-alike-medicines-automated-dispensing
    June 23, 2009 - Study Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets. Citation Text: Ruutiainen HK, Kallio MM, Kuitunen SK. Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets. Eur J Hosp Pharm. 2021…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35759/psn-pdf
    March 08, 2006 - Radiology reporting—where does the radiologist's duty end? March 8, 2006 Garvey CJ; Connolly S. https://psnet.ahrq.gov/issue/radiology-reporting-where-does-radiologists-duty-end The authors present U.S., European, and U.K. positions on the radiologist's responsibility in communicating urgent or abnormal radiology…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36923/psn-pdf
    June 16, 2019 - ISMP medication error report analysis. June 16, 2019 Cohen MR; Smetzer JL. https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-13 This monthly commentary on medication error discusses the effective use of computer alerts, provides examples of problems related to look-alike injection vials, and share…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36385/psn-pdf
    November 01, 2006 - Impact of a statewide reporting system on medication error reduction. November 1, 2006 Rask K; Hawley J; Davis A; Naylor D; Thorpe K. https://psnet.ahrq.gov/issue/impact-statewide-reporting-system-medication-error-reduction The authors analyzed the effectiveness of an Agency for Healthcare Research and Quality (A…
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