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psnet.ahrq.gov/issue/use-hit-adverse-event-reporting-nursing-homes-barriers-and-facilitators
June 02, 2010 - Study
Use of HIT for adverse event reporting in nursing homes: barriers and facilitators.
Citation Text:
Wagner LM, Castle NG, Handler S. Use of HIT for adverse event reporting in nursing homes: barriers and facilitators. Geriatr Nurs. 2013;34(2):112-5. doi:10.1016/j.gerinurse.2012.10.…
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psnet.ahrq.gov/issue/nature-causes-and-clinical-impact-errors-clinical-laboratory-testing-process-leading
May 18, 2022 - Study
The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading to diagnostic error: a voluntary incident report analysis.
Citation Text:
van Moll C, Egberts TCG, Wagner C, et al. The nature, causes, and clinical impact of errors in the clinical…
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psnet.ahrq.gov/issue/machine-learning-evaluation-inequities-and-disparities-associated-nurse-sensitive-indicator
July 19, 2023 - Study
Machine learning evaluation of inequities and disparities associated with nurse sensitive indicator safety events.
Citation Text:
Georgantes ER, Gunturkun F, McGreevy TJ, et al. Machine learning evaluation of inequities and disparities associated with nurse sensitive indicator safe…
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psnet.ahrq.gov/issue/identifying-and-characterizing-preventable-adverse-drug-events-prioritizing-pharmacist
July 15, 2010 - Study
Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospitals.
Citation Text:
Jeon N, Staley B, Johns T, et al. Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospital…
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psnet.ahrq.gov/issue/sensitivity-routine-system-reporting-patient-safety-incidents-nhs-hospital-retrospective
March 28, 2012 - Study
Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review.
Citation Text:
Sari AB-A, Sheldon T, Cracknell A, et al. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retro…
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psnet.ahrq.gov/issue/cost-effectiveness-quality-improvement-programme-reduce-central-line-associated-bloodstream
January 02, 2017 - Study
Cost-effectiveness of a quality improvement programme to reduce central line–associated bloodstream infections in intensive care units in the USA.
Citation Text:
Herzer KR, Niessen L, Constenla DO, et al. Cost-effectiveness of a quality improvement programme to reduce central line-…
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psnet.ahrq.gov/issue/temporal-trends-rates-patient-harm-resulting-medical-care
April 04, 2011 - Study
Classic
Temporal trends in rates of patient harm resulting from medical care.
Citation Text:
Landrigan CP, Parry G, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363(22):2124-34. doi:10.1056/NEJ…
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psnet.ahrq.gov/issue/adverse-events-rehabilitation-hospitals-national-incidence-among-medicare-beneficiaries
January 09, 2019 - Book/Report
Classic
Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.
Citation Text:
Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. Levinson DR. Washington, DC: US Departmen…
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psnet.ahrq.gov/issue/using-human-factors-methods-mitigate-bias-artificial-intelligence-based-clinical-decision
July 10, 2019 - Commentary
Using human factors methods to mitigate bias in artificial intelligence-based clinical decision support.
Citation Text:
Militello LG, Diiulio J, Wilson DL, et al. Using human factors methods to mitigate bias in artificial intelligence-based clinical decision support. J Am Med …
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psnet.ahrq.gov/issue/adverse-events-long-term-care-hospitals-national-incidence-among-medicare-beneficiaries
February 15, 2017 - Book/Report
Adverse Events in Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries.
Citation Text:
Levinson DR. Adverse Events In Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries. Washington, DC: US Department of Health and Human Services, Of…
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psnet.ahrq.gov/issue/barriers-and-enhancers-trust-just-culture-hospital-settings-systematic-review
February 02, 2022 - Review
The barriers and enhancers to trust in a just culture in hospital settings: a systematic review.
Citation Text:
van Marum S, Verhoeven D, de Rooy D. The barriers and enhancers to trust in a just culture in hospital settings: a systematic review. J Patient Saf. 2022;18(7):e1067-e10…
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psnet.ahrq.gov/issue/examining-patient-safety-events-using-behaviour-change-wheel-cross-sectional-analysis
September 20, 2012 - Study
Examining patient safety events using the behaviour change wheel: a cross-sectional analysis.
Citation Text:
Somerville M, Cassidy C, MacPhee S, et al. Examining patient safety events using the behaviour change wheel: a cross-sectional analysis. Jt Comm J Qual Patient Saf. 2025;51(…
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psnet.ahrq.gov/issue/trends-diagnostic-adverse-events-hospital-deaths-longitudinal-analyses-four-retrospective
May 18, 2022 - Study
Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective record review studies.
Citation Text:
Hooftman J, Zwaan L, Sikkens JJ, et al. Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective reco…
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digital.ahrq.gov/2019-year-review/research-summary/using-aviation-technology-prevent-healthcare-errors-health-it
January 01, 2019 - Using Aviation Technology to Prevent Healthcare Errors: The Health IT Black Box
Similar to the airline industry’s use of a “black box” that captures actions leading up to a near miss or error, the health IT black box captures mouse movements and keystrokes made by users of EHRs. This allows for a robust analysis of…
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psnet.ahrq.gov/issue/examining-effect-quality-improvement-initiatives-decreasing-racial-disparities-maternal
May 11, 2022 - Study
Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity.
Citation Text:
Davidson C, Denning S, Thorp K, et al. Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity. BMJ …
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psnet.ahrq.gov/issue/25-year-summary-us-malpractice-claims-diagnostic-errors-1986-2010-analysis-national
July 17, 2019 - Study
25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank.
Citation Text:
Tehrani ASS, Lee HW, Mathews SC, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986-2010: an analysis from the N…
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psnet.ahrq.gov/issue/use-patient-complaints-identify-diagnosis-related-safety-concerns-mixed-method-evaluation
April 13, 2022 - Study
Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.
Citation Text:
Giardina TD, Korukonda S, Shahid U, et al. Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation. BMJ Qual Saf. 2021;30(12…
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psnet.ahrq.gov/issue/facilitators-and-barriers-care-transitions-comparing-perspectives-hospital-and-community
July 21, 2021 - Study
Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staff.
Citation Text:
Carman E-M, Fray M, Waterson P. Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staf…
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psnet.ahrq.gov/issue/hemodialysis-bleeding-events-and-deaths-18-year-retrospective-analysis-patient-safety-and
June 23, 2021 - Study
Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration.
Citation Text:
Walton E, Charles M, Morrish W, et al. Hemodialysis bleeding events and deaths: an 18-year retrospectiv…
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/monitor-patient-outcomes
August 01, 2025 - An official website of the Department of Health & Human Services
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