AHRQ Patient Safety Network

The Collection > Forcing Functions

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•Device-related Complications (3)

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STUDY

Errors with concentrated epinephrine in otolaryngology.

Shah RK, Hoy E, Roberson DW, Nielsen D. Laryngoscope. 2008 Nov; 118: 1928-30.

COMMENTARY

Staying safe: simple tools for safe surgery.

Karl RC. Bull Am Coll Surg. April 2007;92:16-22.

STUDY

Process changes to increase compliance with the Universal Protocol for bedside procedures.

Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.

COMMENTARY

Eptifibatide Epilogue

Churchill WW, Fiumara K. AHRQ WebM&M [serial online]. April 2009.

STUDY

Identifying opportunities for quality improvement in surgical site infection prevention.

Gagliardi AR, Eskicioglu C, McKenzie M, Fenech D, Nathens A, McLeod R. Am J Infect Control. 2009;37:398-402.

COMMENTARY

Too Tight Control.

Rubin HR, Fajtova VT. AHRQ WebM&M [serial online]. May 2004.

COMMENTARY

Checklists to reduce diagnostic errors.

Ely JW, Graber ML, Croskerry P. Acad Med. 2011;86:307-313.

COMMENTARY

Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience

Conway JB, Weingart SN. AHRQ WebM&M [serial online]. May 2005.

COMMENTARY

Around the Block.

Minichiello T. AHRQ WebM&M [serial online]. March 2005.

COMMENTARY

On O.R. Off?

Leonard M. AHRQ WebM&M [serial online]. March 2005.

REVIEW

What have we learned about interventions to reduce medical errors?

Woodward HI, Mytton OT, Lemer C, et al. Annu Rev Public Health. 2010;31:479-497.

COMMENTARY

Use of the common gas outlet for supplementary oxygen during Caesarean section.

Edsell ME, Erasmus PD. Anaesthesia. 2005;60:1152-1153.

COMMENTARY

Double Dosing, by the Rules

Cohen H. AHRQ WebM&M [serial online]. February/March 2009.

STUDY

Management of test results in family medicine offices.

Elder NC, McEwen TR, Flach JM, Gallimore JJ. Ann Fam Med. 2009;7:343-351.

COMMENTARY

Check the Wristband.

Rosenthal MM. AHRQ WebM&M [serial online]. July 2003.

STUDY

Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention.

Tsai TT, Maddox TM, Roe MT, et al; National Cardiovascular Data Registry. JAMA. 2009;302:2458-2464.

BOOK/REPORT classic

The Design of Everyday Things.

Norman DA. New York, NY: Basic Books; 2002.

COMMENTARY

Medication orders are written clearly and transcribed accurately – implementing Medication Management Standard 3.20 and National Patient Safety Goal 2b.

Laselle TJ,May SK. Hosp Pharm. 2006;41:82-87.

REVIEW

Enteral feeding misconnections: an update.

Guenter P, Hicks RW, Simmons D. Nutr Clin Pract. 2009;24:325-334.

STUDY

Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement.

Render ML, Hasselbeck R, Freyberg RW, Hofer TP, Sales AE, Almenoff PL; VA ICU Clinical Advisory Group. BMJ Qual Saf. 2011;20:725-732.

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