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Language discordance and patient care-Babel. | PSNet

psnet.ahrq.gov/issue/language-discordance-and-patient-care-babel

October 30, 2024 - Commentary Language discordance and patient care-Babel. Citation Text: Huson TA. Language discordance and patient care-Babel. JAMA Intern Med. 2024;184(11):1287-1288. doi:10.1001/jamainternmed.2024.4273. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote…

Rapid response teams and failure to rescue: one community's experience. | PSNet

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March 14, 2022 - Study Rapid response teams and failure to rescue: one community's experience. Citation Text: Hammer JA, Jones TL, Brown SA. Rapid response teams and failure to rescue: one community's experience. J Nurs Care Qual. 2012;27(4):352-8. doi:10.1097/NCQ.0b013e31825a8e2f. Copy Citation Fo…

Differences in medication knowledge and risk of errors between graduating nursing students and working registered nurses: comparative study. | PSNet

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December 29, 2014 - Study Differences in medication knowledge and risk of errors between graduating nursing students and working registered nurses: comparative study. Citation Text: Simonsen BO, Daehlin GK, Johansson I, et al. Differences in medication knowledge and risk of errors between graduating nursing…

Using an objective structured clinical examination to test adherence to Joint Commission National Patient Safety Goal–associated behaviors. | PSNet

psnet.ahrq.gov/issue/using-objective-structured-clinical-examination-test-adherence-joint-commission-national

September 26, 2012 - Study Using an objective structured clinical examination to test adherence to Joint Commission National Patient Safety Goal–associated behaviors. Citation Text: Pernar LIM, Shaw T, Pozner CN, et al. Using an Objective Structured Clinical Examination to test adherence to Joint Commissio…

Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error. | PSNet

psnet.ahrq.gov/issue/mortality-and-morbidity-rounds-mmr-pathology-relative-contribution-cognitive-bias-vs-systems

May 18, 2022 - Study Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error. Citation Text: Eichbaum Q, Adkins B, Craig-Owens L, et al. Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias…

Learning from no-fault treatment injury claims to improve the safety of older patients. | PSNet

psnet.ahrq.gov/issue/learning-no-fault-treatment-injury-claims-improve-safety-older-patients

September 27, 2023 - Study Learning from no-fault treatment injury claims to improve the safety of older patients. Citation Text: Wallis KA. Learning from no-fault treatment injury claims to improve the safety of older patients. Ann Fam Med. 2015;13(5):472-4. doi:10.1370/afm.1810. Copy Citation Format:…

Evaluation of detected medication errors within the operating room at an academic medical center. | PSNet

psnet.ahrq.gov/issue/evaluation-detected-medication-errors-within-operating-room-academic-medical-center

October 19, 2022 - Study Evaluation of detected medication errors within the operating room at an academic medical center. Citation Text: Wolf M, Rolf J, Nelson D, et al. Evaluation of detected medication errors within the operating room at an academic medical center. Hosp Pharm. 2023;58(3):309-314. doi:10…

The end of the beginning: patient safety five years after 'To Err Is Human.' | PSNet

psnet.ahrq.gov/issue/end-beginning-patient-safety-five-years-after-err-human

March 02, 2011 - Commentary Classic The end of the beginning: patient safety five years after 'To Err Is Human.' Citation Text: Wachter RM. The End Of The Beginning: Patient Safety Five Years After ‘To Err Is Human’. Health Aff. 2004;23(Suppl1). doi:10.1377/hlthaff.w4.534. C…

The influence of formulation and medicine delivery system on medication administration errors in care homes for older people. | PSNet

psnet.ahrq.gov/issue/influence-formulation-and-medicine-delivery-system-medication-administration-errors-care

March 23, 2011 - Study The influence of formulation and medicine delivery system on medication administration errors in care homes for older people. Citation Text: Alldred DP, Standage C, Fletcher O, et al. The influence of formulation and medicine delivery system on medication administration errors in…

E-prescribing errors in community pharmacies: exploring consequences and contributing factors. | PSNet

psnet.ahrq.gov/issue/e-prescribing-errors-community-pharmacies-exploring-consequences-and-contributing-factors

January 07, 2015 - Study E-prescribing errors in community pharmacies: exploring consequences and contributing factors. Citation Text: Odukoya OK, Stone JA, Chui MA. E-prescribing errors in community pharmacies: exploring consequences and contributing factors. Int J Med Inform. 2014;83(6):427-37. doi:10.10…

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. | PSNet

psnet.ahrq.gov/issue/communication-failures-patient-sign-out-and-suggestions-improvement-critical-incident

April 16, 2008 - Study Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Citation Text: Arora VM, Johnson JK, Lovinger D, et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Hea…

IOM: shorten residents' work shifts to reduce fatigue, improve patient safety. | PSNet

psnet.ahrq.gov/issue/iom-shorten-residents-work-shifts-reduce-fatigue-improve-patient-safety

January 31, 2024 - Journal Article IOM: shorten residents' work shifts to reduce fatigue, improve patient safety. Citation Text: Kuehn BM. IOM: Shorten residents' work shifts to reduce fatigue, improve patient safety. JAMA. 2009;301(3):259-61. doi:10.1001/jama.2008.940. Copy Citation Format: …

National Action Plan for Adverse Drug Event Prevention. | PSNet

psnet.ahrq.gov/issue/national-action-plan-adverse-drug-event-prevention

October 16, 2013 - Book/Report National Action Plan for Adverse Drug Event Prevention. Citation Text: National Action Plan for Adverse Drug Event Prevention. Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health and Human Services; September 2014. Copy Cita…

Dissemination of Lean methods to improve Pap testing quality and patient safety. | PSNet

psnet.ahrq.gov/issue/dissemination-lean-methods-improve-pap-testing-quality-and-patient-safety

June 14, 2011 - Study Dissemination of Lean methods to improve Pap testing quality and patient safety. Citation Text: Raab SS, Andrew-JaJa C, Grzybicki DM, et al. Dissemination of Lean methods to improve Pap testing quality and patient safety. J Low Genit Tract Dis. 2009;12(2):103-110. doi:10.1097/lgt.0…

SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and mortality conference presentations. | PSNet

psnet.ahrq.gov/issue/sbar-mm-feasible-reliable-and-valid-tool-assess-quality-surgical-morbidity-and-mortality

July 02, 2014 - Study SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and mortality conference presentations. Citation Text: Mitchell EL, Lee DY, Arora S, et al. SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and …

A framework for patient safety: a defense nuclear industry-based high-reliability model. | PSNet

psnet.ahrq.gov/issue/framework-patient-safety-defense-nuclear-industry-based-high-reliability-model

June 14, 2017 - Commentary A framework for patient safety: a defense nuclear industry-based high-reliability model. Citation Text: Birnbach DJ, Rosen LF, Williams L, et al. A framework for patient safety: a defense nuclear industry--based high-reliability model. Jt Comm J Qual Patient Saf. 2013;39(5):…

The role of error in organizing behaviour. | PSNet

psnet.ahrq.gov/issue/role-error-organizing-behaviour

April 21, 2011 - Study Classic The role of error in organizing behaviour. Citation Text: Rasmussen J. The role of error in organizing behaviour. Qual Saf Health Care. 2003;12(5):377-383. doi:10.1136/qhc.12.5.377. Copy Citation Format: DOI Google Scholar BibTeX End…

Creating a just culture in the perioperative setting. | PSNet

psnet.ahrq.gov/issue/creating-just-culture-perioperative-setting

July 13, 2009 - Commentary Creating a just culture in the perioperative setting. Citation Text: Hooven K, Altmiller G. Creating a just culture in the perioperative setting. AORN J. 2024;119(2):152-160. doi:10.1002/aorn.14074. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML E…

Nurses' responses to medication errors: suggestions for the development of organizational strategies to improve reporting. | PSNet

psnet.ahrq.gov/issue/nurses-responses-medication-errors-suggestions-development-organizational-strategies-improve

December 16, 2020 - Study Nurses' responses to medication errors: suggestions for the development of organizational strategies to improve reporting. Citation Text: Covell CL, Ritchie JA. Nurses' responses to medication errors: suggestions for the development of organizational strategies to improve reporti…

Dynamics of dignity and safety: a discussion. | PSNet

psnet.ahrq.gov/issue/dynamics-dignity-and-safety-discussion

September 07, 2022 - Commentary Dynamics of dignity and safety: a discussion. Citation Text: Goodwin D, Mesman J, Verkerk M, et al. Dynamics of dignity and safety: a discussion. BMJ Qual Saf. 2018;27(6):488-491. doi:10.1136/bmjqs-2017-007159. Copy Citation Format: DOI Google Scholar PubMed BibT…

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