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psnet.ahrq.gov/issue/prospective-multicenter-study-pharmacist-activities-resulting-medication-error-interception
December 14, 2011 - Study
A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department.
Citation Text:
Patanwala AE, Sanders AB, Thomas MC, et al. A prospective, multicenter study of pharmacist activities resulting in medication error int…
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psnet.ahrq.gov/issue/diagnostic-errors-inserted-tubes-lines-and-catheters-children
September 11, 2019 - Study
Diagnostic errors with inserted tubes, lines and catheters in children.
Citation Text:
Fuentealba I, Taylor GA. Diagnostic errors with inserted tubes, lines and catheters in children. Pediatr Radiol. 2012;42(11):1305-15. doi:10.1007/s00247-012-2462-7.
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psnet.ahrq.gov/issue/utilizing-systems-and-design-thinking-approach-improving-well-being-within-health
March 10, 2021 - Book/Report
Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care.
Citation Text:
Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care. Kreit…
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psnet.ahrq.gov/issue/yours-learning-organization
March 18, 2019 - Newspaper/Magazine Article
Is yours a learning organization?
Citation Text:
Garvin DA, Edmondson A, Gino F. Is yours a learning organization? Harv Bus Rev. 2008;86(3):109-16, 134.
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psnet.ahrq.gov/issue/managing-unnecessary-variability-patient-demand-reduce-nursing-stress-and-improve-patient
August 04, 2021 - Study
Managing unnecessary variability in patient demand to reduce nursing stress and improve patient safety.
Citation Text:
Litvak E, Buerhaus P, Davidoff F, et al. Managing unnecessary variability in patient demand to reduce nursing stress and improve patient safety. Jt Comm J Qual Pat…
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psnet.ahrq.gov/issue/economic-burden-patient-safety-targets-acute-care-systematic-review
April 05, 2013 - Review
The economic burden of patient safety targets in acute care: a systematic review.
Citation Text:
Mittmann N, Matlow A. The economic burden of patient safety targets in acute care: a systematic review. Drug Healthc Patient Saf. 2012. doi:10.2147/dhps.s33288.
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psnet.ahrq.gov/issue/report-6-managing-risk-and-minimising-mistakes-services-children-and-families
June 13, 2012 - Book/Report
Report 6: Managing Risk and Minimising Mistakes in Services to Children and Families.
Citation Text:
Report 6: Managing Risk and Minimising Mistakes in Services to Children and Families. Bostock L, Bairstow S, Fish S, et al. London, UK: Social Care Institute for Excellenc…
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psnet.ahrq.gov/issue/what-diagnostic-safety-review-safety-science-paradigms-and-rethinking-paths-improving
April 12, 2023 - Review
What is diagnostic safety? A review of safety science paradigms and rethinking paths to improving diagnosis.
Citation Text:
Choi JJ. What is diagnostic safety? A review of safety science paradigms and rethinking paths to improving diagnosis. Diagnosis (Berl). 2024;11(4):369-373. d…
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psnet.ahrq.gov/issue/promoting-patient-safety-results-teamstepps-initiative
October 17, 2012 - Commentary
Promoting patient safety: results of a TeamSTEPPS initiative.
Citation Text:
Gaston T, Short N, Ralyea C, et al. Promoting patient safety: results of a TeamSTEPPS initiative. J Nurs Adm. 2016;46(4):201-207. doi:10.1097/nna.0000000000000333.
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psnet.ahrq.gov/issue/evaluating-sample-medications-primary-care-practice-based-research-network-study
July 12, 2010 - Study
Evaluating sample medications in primary care: a practice-based research network study.
Citation Text:
Hansen LB, Saseen JJ, Westfall JM, et al. Evaluating sample medications in primary care: a practice-based research network study. Jt Comm J Qual Patient Saf. 2006;32(12):688-692…
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psnet.ahrq.gov/issue/development-and-sustainability-inpatient-outpatient-discharge-handoff-tool-quality
August 04, 2015 - Study
Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project.
Citation Text:
Moy NY, Lee SJ, Chan T, et al. Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project. Jt C…
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psnet.ahrq.gov/issue/daily-goals-communication-sheet-simple-and-novel-tool-improved-communication-and-care
October 14, 2009 - Commentary
The Daily Goals Communication Sheet: a simple and novel tool for improved communication and care.
Citation Text:
Schwartz JM, Nelson KL, Saliski M, et al. The daily goals communication sheet: a simple and novel tool for improved communication and care. Jt Comm J Qual Patient S…
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psnet.ahrq.gov/issue/hospital-nurses-perceptions-human-factors-contributing-nursing-errors
October 04, 2017 - Study
Hospital nurses' perceptions of human factors contributing to nursing errors.
Citation Text:
Roth C, Wieck L, Fountain R, et al. Hospital nurses' perceptions of human factors contributing to nursing errors. J Nurs Adm. 2015;45(5):263-9. doi:10.1097/NNA.0000000000000196.
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psnet.ahrq.gov/issue/clinical-transformation-ascension-health-eliminating-all-preventable-injuries-and-deaths
January 05, 2017 - Commentary
The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths.
Citation Text:
Pryor DB, Tolchin SF, Hendrich A, et al. The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths. Jt Comm J Qual Patient Sa…
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psnet.ahrq.gov/issue/getting-message-quality-improvement-initiative-reduce-pages-sent-wrong-physician
April 30, 2014 - Study
Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician.
Citation Text:
Wong BM, Cheung M, Dharamshi H, et al. Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician. BMJ Qual Saf. 2012;21(10):85…
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psnet.ahrq.gov/issue/labeling-morphine-milligram-equivalents-opioid-packaging-potential-patient-safety
March 06, 2019 - Review
Labeling morphine milligram equivalents on opioid packaging: a potential patient safety intervention.
Citation Text:
Stone AB, Urman RD, Kaye AD, et al. Labeling Morphine Milligram Equivalents on Opioid Packaging: a Potential Patient Safety Intervention. Curr Pain Headache Rep. 20…
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psnet.ahrq.gov/issue/recommendations-british-committee-standards-haematology-and-national-patient-safety-agency
November 12, 2014 - Organizational Policy/Guidelines
Recommendations from the British Committee for Standards in Haematology and National Patient Safety Agency.
Citation Text:
Baglin TP, Cousins D, Keeling DM, et al. Safety indicators for inpatient and outpatient oral anticoagulant care: [corrected] Recom…
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psnet.ahrq.gov/issue/implementation-protocol-reduce-occurrence-retained-sponges-after-vaginal-delivery
May 18, 2022 - Commentary
Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery.
Citation Text:
Lutgendorf MA, Schindler LL, Hill JB, et al. Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery. Mil Med. 2011;176(6):702-704.…
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psnet.ahrq.gov/issue/framework-direct-observation-performance-and-safety-healthcare
November 15, 2023 - Commentary
Framework for direct observation of performance and safety in healthcare.
Citation Text:
Catchpole K, Neyens DM, Abernathy J, et al. Framework for direct observation of performance and safety in healthcare. BMJ Qual Saf. 2017;26(12):1015-1021. doi:10.1136/bmjqs-2016-006407.
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psnet.ahrq.gov/issue/increasing-physician-reporting-diagnostic-learning-opportunities
March 23, 2022 - Study
Increasing physician reporting of diagnostic learning opportunities.
Citation Text:
Marshall TL, Ipsaro AJ, Le M, et al. Increasing physician reporting of diagnostic learning opportunities. Pediatrics. 2021;147(1):e20192400. doi:10.1542/peds.2019-2400.
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