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psnet.ahrq.gov/issue/prospective-study-patient-safety-operating-room
July 25, 2012 - Study
Classic
A prospective study of patient safety in the operating room.
Citation Text:
Christian CK, Gustafson ML, Roth EM, et al. A prospective study of patient safety in the operating room. Surgery. 2006;139(2):159-173.
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Format:
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psnet.ahrq.gov/node/33755/psn-pdf
September 01, 2013 - What We've Learned About Leveraging Leadership and
Culture to Affect Change and Improve Patient Safety
September 1, 2013
Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve
Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/what-weve-learned-ab…
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psnet.ahrq.gov/issue/hardwiring-safety-computer-system-one-hospitals-actions-provide-technology-support-u-500
February 24, 2016 - Newspaper/Magazine Article
Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin.
Citation Text:
Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin. ISMP Medicatio…
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psnet.ahrq.gov/node/35314/psn-pdf
August 31, 2005 - The health factory.
August 31, 2005
Spear SJ.
https://psnet.ahrq.gov/issue/health-factory
In this editorial, the author suggests that health care organizations approach error the way other industries
do, by constantly evaluating and solving problems, rather than working around them.
https://psnet.ahrq.gov/issue/h…
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psnet.ahrq.gov/issue/selected-medication-safety-risks-manage-2016-might-otherwise-fall-radar-screen-part-1-and
March 09, 2016 - Newspaper/Magazine Article
Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2.
Citation Text:
Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2. ISMP Medicat…
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psnet.ahrq.gov/issue/accelerating-uptake-safety-initiatives-and-guidelines-role-implementation-science
November 26, 2014 - February 8, 2006
Injectable Opioid Shortages: Suggestions for Management and Conservation
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psnet.ahrq.gov/issue/fourth-cause-campaign
April 22, 2009 - October 5, 2005
Injectable Opioid Shortages: Suggestions for Management and Conservation
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psnet.ahrq.gov/issue/reducing-patient-risk-prescription-instruction-errors-six-sigma-approach
October 17, 2012 - April 23, 2021
Injectable Opioid Shortages: Suggestions for Management and Conservation
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
February 01, 2006 - industries
Review cognitive error
Describe the complex dynamics of transitions in emergency care
Provide suggestions
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psnet.ahrq.gov/node/33749/psn-pdf
April 01, 2013 - Communication failures in patient sign-out
and suggestions for improvement: a critical incident analysis
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
November 01, 2012 - Anesthesia in cases of poor surgical risk: some suggestions for decreasing the risk.
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psnet.ahrq.gov/node/33815/psn-pdf
September 01, 2016 - Suggestions to
increase patient safety in telemedicine include: (i) patient safety awareness should
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psnet.ahrq.gov/node/33910/psn-pdf
May 01, 2016 - Quick Tips—When Getting A Prescription.
May 1, 2016
Agency for Healthcare Research and Quality; AHRQ.
https://psnet.ahrq.gov/issue/quick-tips-when-getting-prescription
This Web site suggests questions that all patients should ask a physician, nurse, and/or pharmacist when
they receive a medication prescription.
h…
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psnet.ahrq.gov/node/38247/psn-pdf
June 27, 2018 - Debriefing for patient safety.
June 27, 2018
Turner SH, Kurtz WD. Patient Saf Qual Healthc. November/December 2008:5:42-44,46.
https://psnet.ahrq.gov/issue/debriefing-patient-safety
This article provides guidelines for effective clinical debriefings and suggests how to position these
conversations as learning oppo…
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psnet.ahrq.gov/node/36534/psn-pdf
March 09, 2009 - Standardizing hand-off processes.
March 9, 2009
Gregory BSC. Standardizing hand-off processes. AORN J. 2006;84(6):1059-61.
https://psnet.ahrq.gov/issue/standardizing-hand-processes
The author suggests ways to improve hand-off communications and provides an assessment form to assist
staff in detecting weaknesses in…
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psnet.ahrq.gov/node/33611/psn-pdf
July 01, 2005 - In Conversation with…Christopher P. Landrigan, MD
April 1, 2005
In Conversation with…Christopher P. Landrigan, MD. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
Editor's Note: In October 2004, in what immediately became a landmark paper in patient safety, Dr.…
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psnet.ahrq.gov/node/49610/psn-pdf
October 01, 2010 - "Recurrent" Appendicitis
October 1, 2010
Greenberg CC. "Recurrent" Appendicitis. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/recurrent-appendicitis
The Case
An 85-year-old man presented to the emergency department (ED) with right lower quadrant pain. On
physical examination, the patient showed rebound t…
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psnet.ahrq.gov/node/40299/psn-pdf
April 16, 2018 - Medication errors in the emergency department: need for
pharmacy involvement?
April 16, 2018
https://psnet.ahrq.gov/issue/medication-errors-emergency-department-need-pharmacy-involvement
This piece reports on the prevalence of medication errors in the emergency department and suggests
expanding pharmacy involvemen…
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psnet.ahrq.gov/node/40525/psn-pdf
June 15, 2011 - The normalization of deviance: what are the perioperative
risks?
June 15, 2011
McNamara SA. The normalization of deviance: what are the perioperative risks? AORN J. 2011;93(6):796-
801. doi:10.1016/j.aorn.2011.02.009.
https://psnet.ahrq.gov/issue/normalization-deviance-what-are-perioperative-risks
This commentary…
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psnet.ahrq.gov/node/40626/psn-pdf
July 02, 2014 - Time to sign off on signout.
July 2, 2014
Stein DM, Stetson PD. Commentary: time to sign off on signout. Acad Med. 2011;86(7):804-6.
doi:10.1097/ACM.0b013e31821d8409.
https://psnet.ahrq.gov/issue/time-sign-signout
This commentary suggests standardized sign-outs can improve communication and handoffs.
https://psne…