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psnet.ahrq.gov/issue/medication-errors-and-adverse-drug-events-intensive-care-unit-direct-observation-approach
August 26, 2011 - Study
Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection.
Citation Text:
Kopp BJ, Erstad BL, Allen ME, et al. Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Crit…
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psnet.ahrq.gov/issue/catastrophic-drug-errors-involving-tranexamic-acid-administered-during-spinal-anaesthesia
September 23, 2020 - Review
Emerging Classic
Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia.
Citation Text:
Patel S, Robertson B, McConachie I. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaes…
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psnet.ahrq.gov/issue/role-purple-pens-learning-prescribe
June 17, 2020 - Commentary
The role of purple pens in learning to prescribe.
Citation Text:
Kinston R, McCarville N, Hassell A. The role of purple pens in learning to prescribe. Clin Teach. 2019;16(6):598-603. doi:10.1111/tct.12991.
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psnet.ahrq.gov/issue/correlation-between-hospital-rating-agencies-data-analysis-and-recommendation
April 05, 2023 - Study
Correlation between hospital rating agencies' data: an analysis and recommendation.
Citation Text:
Sondheim SE, Mattie A, Vigil J, et al. Correlation between hospital rating agencies’ data: An analysis and recommendation. J Healthc Risk Manag. 2020;40(3):18-24. doi:10.1002/jhrm.214…
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psnet.ahrq.gov/issue/aspen-safe-practices-enteral-nutrition-therapy
June 12, 2018 - Organizational Policy/Guidelines
ASPEN Safe Practices for Enteral Nutrition Therapy.
Citation Text:
Boullata JI, Carrera AL, Harvey L, et al. ASPEN Safe Practices for Enteral Nutrition Therapy. JPEN J Parenter Enteral Nutr. 2017;41(1):15-103. doi:10.1177/0148607116673053.
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psnet.ahrq.gov/issue/do-first-opinions-affect-second-opinions
October 07, 2020 - Study
Do first opinions affect second opinions?
Citation Text:
Vashitz G, Pliskin JS, Parmet Y, et al. Do First Opinions Affect Second Opinions? J Gen Intern Med. 2012;27(10). doi:10.1007/s11606-012-2056-y.
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psnet.ahrq.gov/issue/medicare-nonpayment-hospital-falls-and-unintended-consequences
October 19, 2022 - Commentary
Medicare nonpayment, hospital falls, and unintended consequences.
Citation Text:
Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. N Engl J Med. 2009;360(23):2390-3. doi:10.1056/NEJMp0900963.
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psnet.ahrq.gov/issue/clinical-nurse-specialist-intervention-facilitate-safe-transfer-icu
January 15, 2014 - Commentary
A clinical nurse specialist intervention to facilitate safe transfer from ICU.
Citation Text:
St-Louis L, Brault D. A clinical nurse specialist intervention to facilitate safe transfer from ICU. Clin Nurse Spec. 2011;25(6):321-6. doi:10.1097/NUR.0b013e318233eaab.
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psnet.ahrq.gov/issue/algorithmic-prediction-failure-modes-healthcare
September 06, 2023 - Study
Algorithmic prediction of failure modes in healthcare.
Citation Text:
Kobo-Greenhut A, Sharlin O, Adler Y, et al. Algorithmic prediction of failure modes in healthcare. Int J Qual Health Care. 2021;33(1):mzaa151. doi:10.1093/intqhc/mzaa151.
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psnet.ahrq.gov/issue/medicaid-hospital-financial-stress-and-incidence-adverse-medical-events-children
December 21, 2022 - Study
Medicaid, hospital financial stress, and the incidence of adverse medical events for children.
Citation Text:
Smith RB, Dynan L, Fairbrother G, et al. Medicaid, hospital financial stress, and the incidence of adverse medical events for children. Health Serv Res. 2012;47(4):1621-4…
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psnet.ahrq.gov/issue/leveraging-trainees-improve-quality-and-safety-point-care-three-models-engagement
September 20, 2017 - Commentary
Leveraging trainees to improve quality and safety at the point of care: three models for engagement.
Citation Text:
Faherty LJ, Mate KS, Moses JM. Leveraging Trainees to Improve Quality and Safety at the Point of Care: Three Models for Engagement. Acad Med. 2016;91(4):503-9. d…
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psnet.ahrq.gov/issue/switch-safety-perioperative-hand-tools
October 18, 2023 - Commentary
SWITCH for safety: perioperative hand-off tools.
Citation Text:
Johnson F, Logsdon P, Fournier K, et al. SWITCH for safety: Perioperative hand-off tools. AORN J. 2013;98(5):494-504; quiz 505-7. doi:10.1016/j.aorn.2013.08.016.
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psnet.ahrq.gov/issue/impact-pharmacotherapy-alerting-system-medication-errors
November 10, 2015 - Study
Impact of a pharmacotherapy alerting system on medication errors.
Citation Text:
Natali BJ, Varkey AC, Garey KW, et al. Impact of a pharmacotherapy alerting system on medication errors. American Journal of Health-System Pharmacy. 2012;70(1). doi:10.2146/ajhp120126.
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psnet.ahrq.gov/issue/interruptions-during-delivery-high-risk-medications
September 26, 2016 - Study
Interruptions during the delivery of high-risk medications.
Citation Text:
Trbovich PL, Prakash V, Stewart J, et al. Interruptions during the delivery of high-risk medications. J Nurs Adm. 2010;40(5):211-8. doi:10.1097/NNA.0b013e3181da4047.
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psnet.ahrq.gov/issue/scholarly-pathway-quality-improvement-and-patient-safety
December 18, 2017 - Commentary
A scholarly pathway in quality improvement and patient safety.
Citation Text:
Ferguson CC, Lamb G. A Scholarly Pathway in Quality Improvement and Patient Safety. Acad Med. 2015;90(10):1358-62. doi:10.1097/ACM.0000000000000772.
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psnet.ahrq.gov/issue/who-makes-prescribing-decisions-hospital-inpatients-observational-study
January 30, 2013 - Study
Who makes prescribing decisions in hospital inpatients? An observational study.
Citation Text:
Ross S, Hamilton L, Ryan C, et al. Who makes prescribing decisions in hospital inpatients? An observational study. Postgrad Med J. 2012;88(1043):507-10. doi:10.1136/postgradmedj-2011-13…
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psnet.ahrq.gov/issue/comparative-performance-pediatric-weight-estimation-techniques-human-factor-errors-analysis
March 30, 2022 - Study
Comparative performance of pediatric weight estimation techniques: a human factor errors analysis.
Citation Text:
Abdel-Rahman SM, Jacobsen R, Watts JL, et al. Comparative performance of pediatric weight estimation techniques: a human factor errors analysis. Pediatr Emerg Care. 201…
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psnet.ahrq.gov/issue/family-involvement-patient-safety-and-suicide-prevention-mental-healthcare-ethnographic-study
February 19, 2020 - Study
Family involvement, patient safety and suicide prevention in mental healthcare: ethnographic study.
Citation Text:
Gorman LS, Littlewood DL, Quinlivan L, et al. Family involvement, patient safety and suicide prevention in mental healthcare: ethnographic study. BJPsych Open. 2023;9(…
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psnet.ahrq.gov/issue/implementing-perioperative-handoff-tool-improve-postprocedural-patient-transfers
February 29, 2012 - Commentary
Implementing a perioperative handoff tool to improve postprocedural patient transfers.
Citation Text:
Petrovic MA, Martinez EA, Aboumatar HJ. Implementing a perioperative handoff tool to improve postprocedural patient transfers. Jt Comm J Qual Patient Saf. 2012;38(3):135-42.
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psnet.ahrq.gov/issue/5th-national-audit-project-nap5-accidental-awareness-during-general-anaesthesia-protocol
November 12, 2014 - Study
5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods, and analysis of data.
Citation Text:
Pandit JJ, Andrade J, Bogod DG, et al. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: protocol, metho…