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Burger C, Eaton P, Hess K, et al. Patient Saf Qual Healthc. December 12, 2017.
Systems-based improvements are key to achieving patient safety. This article discusses the value of applying sociotechnical methods in all care environments to enhance practice and suggests that cognitive engineering can help uncover system flaws and design interventions.
Patient Safety Certificate Program.
Armstrong Institute for Patient Safety and Quality. August 13-17, 2018; Constellation Energy Building, Baltimore, MD.
Human Factors and Technology in the ICU.
Wung SF, ed. Crit Care Nurs Clin North Am. 2018;30:179-310.
A call for a systems-thinking approach to medication adherence: stop blaming the patient.
Lauffenburger JC, Choudhry NK. JAMA Internal Med. 2018 May 21; [Epub ahead of print].
Patient Safety in the Context of Perinatal, Neonatal, and Pediatric Care.
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.
Deriving a framework for a systems approach to agitated patient care in the emergency department.
Wong AH, Ruppel H, Crispino LJ, Rosenberg A, Iennaco JD, Vaca FE. Jt Comm J Qual Patient Saf. 2018;44:279-292.
Diagnostic performance dashboards: tracking diagnostic errors using big data.
Mane KK, Rubenstein KB, Nassery N, et al. BMJ Qual Saf. 2018;27:567-570.
Workarounds to intended use of health information technology: a narrative review of the human factors engineering literature.
Patterson ES. Hum Factors. 2018;60:281-292.
Considering human factors and developing systems-thinking behaviours to ensure patient safety.
Vosper H, Lim R, Knight C, Bowie P, Edwards B, Hignett S; CIEHF Pharmaceutical Human Factors Special Interest Group. Clinical Pharmacist. 2018;10(2).
FDA Drug Safety Communication: FDA requires labeling changes for prescription opioid cough and cold medicines to limit their use to adults 18 years and older.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2018.
Implementation of diagnostic pauses in the ambulatory setting.
Huang GC, Kriegel G, Wheaton C, et al. BMJ Qual Saf. 2018;27:492-497.
The effect of facility characteristics on patient safety, patient experience, and service availability for procedures in non–hospital-affiliated outpatient settings: a systematic review.
Berglas NF, Battistelli MF, Nicholson WK, Sobota M, Urman RD, Roberts SCM. PLoS ONE. 2018;13:e0190975.
To err is human: use of simulation to enhance training and patient safety in anaesthesia.
Higham H, Baxendale B. Br J Anaesth. 2017;119(suppl 1):i106-i114.
Safe labeling practices to minimize medication errors in anesthesia: 5 case reports and review of the literature.
Prakash S, Mullick P, Kumar A, Pawar M. A A Case Rep. 2018;10:261-264.
Twelve tips for embedding human factors and ergonomics principles in healthcare education.
Vosper H, Hignett S, Bowie P. Med Teach. 2018;40:357-363.
Center for Health Care Human Factors.
Armstrong Institute for Patient Safety and Quality.
CVS taps a design legend to reinvent the prescription label. Next stop: the pharmacy.
Kuang C. Fast Company. October 4, 2017.
White paper on recommendation for systems-based practice competency.
Stalter AM, Phillips JM, Dolansky MA. QSEN Institute RN-BSN Task Force. J Nurs Care Qual. 2017;32:354-358.
Workarounds are routinely used by nurses—but are they ethical?
Berlinger N. Am J Nurs. 2017;117:53-55.
Human factors and simulation in emergency medicine.
Hayden EM, Wong AH, Ackerman J, et al. Acad Emerg Med. 2018;25:221-229.
Creating a highly reliable neonatal intensive care unit through safer systems of care.
Panagos PG, Pearlman SA. Clin Perinatol. 2017;44:645-662.
Use of unit-based interventions to improve the quality of care for hospitalized medical patients: a national survey.
O'Leary KJ, Johnson JK, Manojlovich M, Astik GJ, Williams MV. Jt Comm J Qual Patient Saf. 2017;43:573–579.
Administering and monitoring high-alert medications in acute care.
Cajanding JMR. Nurs Stand. 2017;31:42-52.
Health and Social Care Ergonomics: Patient Safety in Practice.
Hignett S, Albolino S, Catchpole K, eds. Ergonomics. 2018;61:1-161.
Pictograms, units and dosing tools, and parent medication errors: a randomized study.
Yin HS, Parker RM, Sanders LM, et al. Pediatrics. 2017;140:e20163237.
Implementation science for ambulatory care safety: a novel method to develop context-sensitive interventions to reduce quality gaps in monitoring high-risk patients.
McDonald KM, Su G, Lisker S, Patterson ES, Sarkar U. Implement Sci. 2017;12:79.
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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