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Bethesda, MD: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. May 21, 2018. PA-18-790; PA-18-791.
This dual-component funding program will support collaborative research and project development projects that explore strategies to reduce medical error in both routine hospital settings and intensive care units.
Higher quality of care and patient safety associated with better NICU work environments.
Lake ET, Hallowell SG, Kutney-Lee A, et al. J Nurs Care Qual. 2016;31:24-32.
AHRQ Health Services Research Projects (R01).
US Department of Health and Human Services. Program Announcement No. PA-14-291.
Another tragic parenteral nutrition compounding error.
ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.
Measuring faculty reflection on adverse patient events: development and initial validation of a case-based learning system.
Wittich CM, Lopez-Jimenez F, Decker LK, et al. J Gen Intern Med. 2011;26:293-298.
PA-PSRS Patient Saf Advis. December 2009;6(suppl 1):1-32.
Engineering a foundation for partnership to improve medication safety during care transitions.
Xiao Y, Abebe E, Gurses AP. J Patient Saf Risk Manag. 2019 Jan 11; [Epub ahead of print].
Payment innovations to improve diagnostic accuracy and reduce diagnostic error.
Berenson R, Singh H. Health Aff (Millwood). 2018;37:1828-1835.
Reducing Diagnostic Errors in Primary Care Pediatrics (Project RedDE!) Toolkit.
Itasca, IL: American Academy of Pediatrics; 2018.
IV push medications survey results—part 1 and part 2.
ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
System-related and cognitive errors in laboratory medicine.
Plebani M. Diagnosis (Berl). 2018;5:191-196.
Diagnostic heuristics in dermatology—part 1 and part 2.
Lowenstein EJ, Sidlow R. Br J Dermatol. 2018;179:1263-1269;1270-1276.
Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research.
Armstrong N. BMJ Qual Saf. 2018;27:571-575.
Diagnostic performance dashboards: tracking diagnostic errors using big data.
Mane KK, Rubenstein KB, Nassery N, et al. BMJ Qual Saf. 2018;27:567-570.
Improving Your Office Testing Process: A Step by Step Guide for Rapid-Cycle Patient Safety and Quality Improvement.
Rockville, MD: Agency for Healthcare Research and Quality; January 2018.
Implementation of diagnostic pauses in the ambulatory setting.
Huang GC, Kriegel G, Wheaton C, et al. BMJ Qual Saf. 2018;27:492-497.
Recognition and prevention of nosocomial malnutrition: a review and a call to action!
Kirkland LL, Shaughnessy E. Am J Med. 2017;130:1345-1350.
Diagnostic errors in primary care pediatrics: Project RedDE.
Rinke ML, Singh H, Heo M, et al. Acad Pediatr. 2018;18:220-227.
Primary care collaboration to improve diagnosis and screening for colorectal cancer.
Schiff GD, Bearden T, Hunt LS, et al. Jt Comm J Qual Patient Saf. 2017;43:338–350.
The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking.
Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. Acad Med. 2017;92:23-30.
Improving Diagnostic Accuracy Project 2016–2017.
Washington, DC: National Quality Forum; October 2016.
Three simple rules to improve medication safety.
Barba V. J Patient Saf. 2016;12:171-172.
Reporting and second-order problem solving can turn short-term fixes into long-term remedies.
ISMP Medication Safety Alert! Acute Care Edition. May 19, 2016;21:1-4.
Pain as the neglected patient safety concern: five years on.
Twycross A, Forgeron P, Chorne J, Blackman C, Finley GA. J Child Health Care. 2016;20:537-541.
Government and industry fail to protect the public when they suggest "carefully following instructions" is enough to prevent vaccine errors.
ISMP Medication Safety Alert! Acute Care Edition. February 25, 2016;21:1-5.
Human factors and quality improvement in the emergency department: reducing potential errors in blood collection.
Bashkin O, Caspi S, Swissa A, Amedi A, Zornano S, Stalnikowicz R. J Patient Saf. 2016 Feb 18; [Epub ahead of print].
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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