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  1. Elimination of emergency department medication errors due to estimated weights. | PSNet

    psnet.ahrq.gov/issue/elimination-emergency-department-medication-errors-due-estimated-weights
    July 08, 2020 - Commentary Elimination of emergency department medication errors due to estimated weights. Citation Text: Greenwalt M, Griffen D, Wilkerson J. Elimination of Emergency Department Medication Errors Due To Estimated Weights. BMJ Qual Improv Rep. 2017;6(1). doi:10.1136/bmjquality.u214416.w5…

  2. Handoff communication between hospital and outpatient dialysis units at patient discharge: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/handoff-communication-between-hospital-and-outpatient-dialysis-units-patient-discharge
    August 20, 2018 - Study Handoff communication between hospital and outpatient dialysis units at patient discharge: a qualitative study. Citation Text: Reilly JB, Marcotte LM, Berns JS, et al. Handoff communication between hospital and outpatient dialysis units at patient discharge: a qualitative study. …

  3. Diagnostic reasoning in cardiovascular medicine. | PSNet

    psnet.ahrq.gov/issue/diagnostic-reasoning-cardiovascular-medicine
    October 27, 2021 - Review Diagnostic reasoning in cardiovascular medicine. Citation Text: Brush JE, Sherbino J, Norman GR. Diagnostic reasoning in cardiovascular medicine. BMJ. 2022;376:e064389. doi:10.1136/bmj-2021-064389. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNot…

  4. Getting the message: a quality improvement initiative to reduce pages sent to the wrong physician. | PSNet

    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…

  5. Hospital nurses' perceptions of human factors contributing to nursing errors. | PSNet

    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. Copy Cita…

  6. The Daily Goals Communication Sheet: a simple and novel tool for improved communication and care. | PSNet

    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…

  7. Impact of drug shortages on U.S. health systems. | PSNet

    psnet.ahrq.gov/issue/impact-drug-shortages-us-health-systems
    September 02, 2016 - Study Impact of drug shortages on U.S. health systems. Citation Text: Kaakeh R, Sweet B, Reilly C, et al. Impact of drug shortages on U.S. health systems. Am J Health Syst Pharm. 2011;68(19):1811-9. doi:10.2146/ajhp110210. Copy Citation Format: DOI Google Scholar PubMed Bib…

  8. Development and implementation of a pediatric patient safety program. | PSNet

    psnet.ahrq.gov/issue/development-and-implementation-pediatric-patient-safety-program
    September 27, 2010 - Commentary Development and implementation of a pediatric patient safety program. Citation Text: Alton M, Frush K, Brandon D, et al. DEVELOPMENT AND IMPLEMENTATION OF A PEDIATRIC PATIENT SAFETY PROGRAM. Adv Neonatal Care. 2006;6(3):104-111. doi:10.1016/j.adnc.2006.02.003. Copy Citatio…

  9. The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths. | PSNet

    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…

  10. Labeling morphine milligram equivalents on opioid packaging: a potential patient safety intervention. | PSNet

    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…

  11. The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System. | PSNet

    psnet.ahrq.gov/issue/high-costs-weak-compliance-new-york-state-hospital-adverse-event-reporting-and-tracking
    July 22, 2020 - Book/Report The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System. Citation Text: The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System. Thompson WC Jr. New York, NY: Off…

  12. Predicting and preventing adverse drug reactions in the very old. | PSNet

    psnet.ahrq.gov/issue/predicting-and-preventing-adverse-drug-reactions-very-old
    April 16, 2018 - Study Predicting and preventing adverse drug reactions in the very old. Citation Text: Merle L, Laroche M-L, Dantoine T, et al. Predicting and preventing adverse drug reactions in the very old. Drugs Aging. 2005;22(5):375-92. Copy Citation Format: Google Scholar PubMed Bi…

  13. Creating a physician-led quality imperative. | PSNet

    psnet.ahrq.gov/issue/creating-physician-led-quality-imperative
    March 20, 2019 - Commentary Creating a physician-led quality imperative. Citation Text: Nelson MF, Merriman CS, Magnusson PT, et al. Creating a physician-led quality imperative. Am J Med Qual. 2014;29(6):508-16. doi:10.1177/1062860613509683. Copy Citation Format: DOI Google Scholar PubMed B…

  14. Transformative learning in a professional development course aimed at addressing disruptive physician behavior: a composite case study. | PSNet

    psnet.ahrq.gov/issue/transformative-learning-professional-development-course-aimed-addressing-disruptive-physician
    February 12, 2020 - Commentary Transformative learning in a professional development course aimed at addressing disruptive physician behavior: a composite case study. Citation Text: Samenow CP, Worley LLM, Neufeld R, et al. Transformative learning in a professional development course aimed at addressing dis…

  15. Evaluating sample medications in primary care: a practice-based research network study. | PSNet

    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…

  16. Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project. | PSNet

    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…

  17. A theory-based instrument to evaluate team communication in the operating room: balancing measurement authenticity and reliability. | PSNet

    psnet.ahrq.gov/issue/theory-based-instrument-evaluate-team-communication-operating-room-balancing-measurement
    June 23, 2010 - Commentary A theory-based instrument to evaluate team communication in the operating room: balancing measurement authenticity and reliability. Citation Text: Lingard LA, Regehr G, Espin S, et al. A theory-based instrument to evaluate team communication in the operating room: balancing …

  18. Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery. | PSNet

    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.…

  19. Recommendations from the British Committee for Standards in Haematology and National Patient Safety Agency. | PSNet

    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…

  20. Increasing physician reporting of diagnostic learning opportunities. | PSNet

    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. Copy Citation Format: …
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