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Dean J, Clarkson J, eds. Future Hosp J. 2018;5:145-187.
The systems approach has long been heralded as a key element to safe patient care. Articles in this special issue explore techniques to engage clinicians and leadership in supporting a systems engineering philosophy to optimize safety improvement efforts.
SEIPS Systems Engineering Initiative for Patient Safety.
University of Florida Center for Simulation, Education, and Safety Research, April 1–5, 2019; The River Club, Jacksonville, FL.
Patient Safety Certificate Program.
Armstrong Institute for Patient Safety and Quality. March 25-29, 2019; Armstrong Institute for Patient Safety and Quality, Baltimore, MD.
Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula
Jed D. Gonzalo, MD, MSc, and Mamta K. Singh, MD, MSc
Pro/con debate: color-coded medication labels.
Janik LS, Vender JS Grissinger M, Litman RS. APSF Newsletter. February 2019;33:72-75.
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].
Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care.
Kahwati LC, Sorensen AV, Teixeira-Poit S, et al. Jt Comm J Qual Patient Saf. 2019 Jan 10; [Epub ahead of print].
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care.
Kreitzer MJ, Carter K, Coffey DS, et al. NAM Perspectives. Washington, DC: National Academy of Medicine; 2019.
Human Factors Engineering
Usability testing of a mobile app to report medication errors anonymously: mixed-methods approach.
George D, Hassali MA, Hss AS. JMIR Hum Factors. 2018;5:e12232.
Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academy of Medicine.
Improving patient safety in developing countries—moving towards an integrated approach.
Elmontsri M, Banarsee R, Majeed A. JRSM Open. 2018;9:2054270418786112.
Patient Safety and Quality Improvement.
Shah RK, ed. Otolaryngol Clin North Am. 2019;52:1-194.
Health Aff (Milwood). 2018;37:1723-1908.
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.
Shifting and sharing: academic physicians' strategies for navigating underperformance and failure.
LaDonna KA, Ginsburg S, Watling C. Acad Med. 2018;93:1713-1718.
What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff.
Keers RN, Plácido M, Bennett K, Clayton K, Brown P, Ashcroft DM. PLoS One. 2018;13:e0206233.
The systems approach at the sharp end.
Cross SRH. Future Hosp J. 2018;5:176-180.
Differences in strength expression on product labels of compounders and conventional manufacturers may lead to dosing errors.
Silver Spring, MD: US Food and Drug Administration; September 29, 2018.
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.
Assessing information sources to elucidate diagnostic process errors in radiologic imaging—a human factors framework.
Cochon L, Lacson R, Wang A, et al. J Am Med Inform Assoc. 2018;25:1507-1515.
Fixed-dose combination antihypertensives and risk of medication errors.
Moriarty F, Bennett K, Fahey T. Heart. 2019;105:204-209.
Effective approaches to control non-actionable alarms and alarm fatigue.
Winters BD. J Electrocardiol. 2018;51:S49-S51.
Complicated: medical missteps are not inevitable.
Yurkiewicz IR. Health Aff (Millwood). 2018 37:7;1178-1181.
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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