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psnet.ahrq.gov/issue/prospective-observational-study-incidence-medication-errors-during-simulated-resuscitation
April 22, 2011 - Study
Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department.
Citation Text:
Kozer E, Seto W, Verjee Z, et al. Prospective observational study on the incidence of medication errors during simulated resus…
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psnet.ahrq.gov/issue/lessons-learned-implementing-principled-approach-resolution-following-patient-harm
February 12, 2020 - Commentary
Lessons learned from implementing a principled approach to resolution following patient harm.
Citation Text:
Smith KM, Smith LL, (Jack) Gentry JC, et al. Lessons learned from implementing a principled approach to resolution following patient harm. J Patient Saf Risk Manag. 201…
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psnet.ahrq.gov/issue/making-patient-safety-centerpiece-medical-liability-reform
December 01, 2019 - Commentary
Making patient safety the centerpiece of medical liability reform.
Citation Text:
Clinton HR, Obama B. Making Patient Safety the Centerpiece of Medical Liability Reform. New England Journal of Medicine. 2006;354(21). doi:10.1056/nejmp068100.
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psnet.ahrq.gov/issue/transitional-chaos-or-enduring-harm-ehr-and-disruption-medicine
August 02, 2015 - Commentary
Transitional chaos or enduring harm? The EHR and the disruption of medicine.
Citation Text:
Rosenbaum L. Transitional Chaos or Enduring Harm? The EHR and the Disruption of Medicine. New Engl J Med. 2015;373(17):1585-1588. doi:10.1056/NEJMp1509961.
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psnet.ahrq.gov/issue/student-mistakes-and-teacher-reactions-bedside-teaching
January 18, 2012 - Study
Student mistakes and teacher reactions in bedside teaching.
Citation Text:
Rubisch HPK, Blaschke A-L, Berberat PO, et al. Student mistakes and teacher reactions in bedside teaching. Adv Health Sci Educ Theory Pract. 2023;28(5):1523-1556. doi:10.1007/s10459-023-10233-y.
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psnet.ahrq.gov/issue/comparison-voluntarily-reported-medication-errors-intensive-care-and-general-care-units
October 26, 2010 - Study
A comparison of voluntarily reported medication errors in intensive care and general care units.
Citation Text:
Kane-Gill SL, Kowiatek JG, Weber RJ. A comparison of voluntarily reported medication errors in intensive care and general care units. Qual Saf Health Care. 2010;19(1):5…
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psnet.ahrq.gov/issue/rapid-response-systems-adult-academic-medical-centers
February 16, 2011 - Study
Rapid response systems in adult academic medical centers.
Citation Text:
Wood KA, Ranji SR, Ide B, et al. Rapid response systems in adult academic medical centers. Jt Comm J Qual Patient Saf. 2009;35(9):475-82, 437.
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psnet.ahrq.gov/issue/learning-mistakes-and-near-mistakes-using-root-cause-analysis-risk-management-tool
June 19, 2024 - Commentary
Learning from mistakes and near mistakes: using root cause analysis as a risk management tool.
Citation Text:
Cerniglia-Lowensen J. Learning From Mistakes and Near Mistakes: Using Root Cause Analysis as a Risk Management Tool. J Radiol Nurs. 2015;34(1). doi:10.1016/j.jradnu.20…
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psnet.ahrq.gov/issue/workforce-perceptions-hospital-safety-culture-development-and-validation-patient-safety
November 18, 2009 - Study
Workforce perceptions of hospital safety culture: development and validation of the patient safety climate in healthcare organizations survey.
Citation Text:
Singer SJ, Meterko M, Baker LC, et al. Workforce perceptions of hospital safety culture: development and validation of the…
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psnet.ahrq.gov/issue/learning-failure-need-independent-safety-investigation-healthcare
September 24, 2018 - Commentary
Learning from failure: the need for independent safety investigation in healthcare.
Citation Text:
Macrae C, Vincent CA. Learning from failure: the need for independent safety investigation in healthcare. J R Soc Med. 2014;107(11):439-443. doi:10.1177/0141076814555939.
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psnet.ahrq.gov/issue/attitudes-and-practices-related-clinical-alarms-follow-survey
June 11, 2014 - Study
Attitudes and practices related to clinical alarms: a follow-up survey.
Citation Text:
Ruppel H, Funk M, Clark T, et al. Attitudes and Practices Related to Clinical Alarms: A Follow-up Survey. Am J Crit Care. 2018;27(2):114-123. doi:10.4037/ajcc2018185.
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psnet.ahrq.gov/issue/online-medication-error-graphic-reports-pilot-north-carolina-nursing-homes
March 24, 2011 - Study
Online medication error graphic reports: a pilot in North Carolina nursing homes.
Citation Text:
Greene SB, Williams CE, Pierson S, et al. Online medication error graphic reports: a pilot in North Carolina nursing homes. J Patient Saf. 2011;7(2):92-8. doi:10.1097/PTS.0b013e31821b4…
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psnet.ahrq.gov/issue/development-medication-safety-and-quality-survey-small-rural-hospitals
July 15, 2010 - Study
Development of a medication safety and quality survey for small rural hospitals.
Citation Text:
Winterstein AG, Johns TE, Campbell KN, et al. Development of a Medication Safety and Quality Survey for Small Rural Hospitals. J Patient Saf. 2017;13(4):249-254. doi:10.1097/PTS.00000000…
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psnet.ahrq.gov/issue/development-and-implementation-oral-sign-out-skills-curriculum
February 15, 2011 - Commentary
Development and implementation of an oral sign-out skills curriculum.
Citation Text:
Horwitz LI, Moin T, Green M. Development and implementation of an oral sign-out skills curriculum. J Gen Intern Med. 2007;22(10):1470-4.
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psnet.ahrq.gov/issue/improving-follow-high-risk-psychiatry-outpatients-resident-year-end-transfer
January 27, 2016 - Study
Improving follow-up of high-risk psychiatry outpatients at resident year-end transfer.
Citation Text:
Young JQ, Pringle Z, Wachter R. Improving follow-up of high-risk psychiatry outpatients at resident year-end transfer. Jt Comm J Qual Patient Saf. 2011;37(7):300-308.
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psnet.ahrq.gov/issue/evolution-procedural-competency-internal-medicine-training
December 15, 2021 - Commentary
The evolution of procedural competency in internal medicine training.
Citation Text:
Sacks CA, Alba GA, Miloslavsky EM. The Evolution of Procedural Competency in Internal Medicine Training. JAMA Intern Med. 2017;177(12):1713-1714. doi:10.1001/jamainternmed.2017.5014.
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psnet.ahrq.gov/issue/resident-duty-hour-regulation-and-patient-safety-establishing-balance-between-concerns-about
May 20, 2009 - Commentary
Resident duty hour regulation and patient safety: establishing a balance between concerns about resident fatigue and adequate training in neurosurgery.
Citation Text:
Grady S, Batjer H, Dacey RG. Resident duty hour regulation and patient safety: establishing a balance betwee…
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psnet.ahrq.gov/issue/resident-shift-handoff-strategies-us-internal-medicine-residency-programs
July 02, 2014 - Study
Resident shift handoff strategies in US internal medicine residency programs.
Citation Text:
Wray CM, Chaudhry S, Pincavage A, et al. Resident Shift Handoff Strategies in US Internal Medicine Residency Programs. JAMA. 2016;316(21):2273-2275. doi:10.1001/jama.2016.17786.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.68_slideshow.ppt
July 01, 2004 - Misuse
Eighteen hours after infusion, the patient developed severe bleeding and hemodynamic instability requiring
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - Over the next 10 minutes, the child’s cardiovascular status deteriorated, requiring epinephrine.