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psnet.ahrq.gov/issue/creating-complex-health-improvement-programs-mindful-organizations-theory-action
October 19, 2022 - Commentary
Creating complex health improvement programs as mindful organizations: from theory to action.
Citation Text:
Issel M, Narasimha KM. Creating complex health improvement programs as mindful organizations: from theory to action. J Health Organ Manag. 2007;21(2):166-83.
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psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients
July 10, 2008 - Review
Disclosing harmful medical errors to patients.
Citation Text:
Gallagher TH, Studdert DM, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med. 2007;356(26):2713-9.
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psnet.ahrq.gov/issue/eight-year-experience-neurosurgical-checklist
September 27, 2023 - Study
Eight-year experience with a neurosurgical checklist.
Citation Text:
Lyons MK. Eight-year experience with a neurosurgical checklist. Am J Med Qual. 2010;25(4):285-8. doi:10.1177/1062860610363305.
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psnet.ahrq.gov/issue/patient-reports-undesirable-events-during-hospitalization
March 28, 2011 - Study
Patient reports of undesirable events during hospitalization.
Citation Text:
Agoritsas T, Bovier PA, Perneger T. Patient reports of undesirable events during hospitalization. J Gen Intern Med. 2005;20(10):922-8.
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psnet.ahrq.gov/issue/towards-framework-select-techniques-error-prediction-supporting-novice-users-healthcare
March 28, 2011 - Review
Towards a framework to select techniques for error prediction: supporting novice users in the healthcare sector.
Citation Text:
Lyons M. Towards a framework to select techniques for error prediction: supporting novice users in the healthcare sector. Appl Ergon. 2009;40(3):379-95…
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psnet.ahrq.gov/issue/challenges-and-opportunities-patient-safety-event-reporting
June 23, 2021 - Commentary
Challenges and opportunities of patient safety event reporting.
Citation Text:
Gong Y. Challenges and opportunities of patient safety event reporting. Stud Health Technol Inform. 2022;291:133-150. doi:10.3233/shti220014.
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psnet.ahrq.gov/issue/effective-discharge-communication-emergency-department
January 24, 2024 - Review
Effective discharge communication in the emergency department.
Citation Text:
Samuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency department. Ann Emerg Med. 2012;60(2):152-9. doi:10.1016/j.annemergmed.2011.10.023.
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psnet.ahrq.gov/issue/silent-epidemic-health-effects-illiteracy
January 12, 2011 - Commentary
The silent epidemic--the health effects of illiteracy.
Citation Text:
Marcus EN. The silent epidemic--the health effects of illiteracy. N Engl J Med. 2006;355(4):339-41.
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psnet.ahrq.gov/issue/can-you-prevent-adverse-drug-events-after-hospital-discharge
September 09, 2009 - Commentary
Can you prevent adverse drug events after hospital discharge?
Citation Text:
Forster AJ. Can you prevent adverse drug events after hospital discharge? CMAJ. 2006;174(7):921-2.
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psnet.ahrq.gov/issue/industrial-and-systems-engineering-and-health-care-critical-areas-research-final-report
November 17, 2010 - Book/Report
Industrial and Systems Engineering and Health Care: Critical Areas of Research: Final Report.
Citation Text:
Industrial and Systems Engineering and Health Care: Critical Areas of Research: Final Report. Valdez RS, Ramly E, Brennan PF. Rockville, MD: Agency for Healthcare Rese…
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psnet.ahrq.gov/issue/patient-safety-investigation-report-services-university-hospital-galway-uhg-and-reflected
June 14, 2017 - Book/Report
Patient Safety Investigation report into services at University Hospital Galway (UHG) and as reflected in the care provided to Savita Halappanavar.
Citation Text:
Patient Safety Investigation report into services at University Hospital Galway (UHG) and as reflected in the ca…
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psnet.ahrq.gov/issue/common-formats-patient-safety-data-collection-and-event-reporting-1
July 03, 2013 - Press Release/Announcement
Common formats for patient safety data collection and event reporting.
Citation Text:
Common formats for patient safety data collection and event reporting. Federal Register. Rockville, MD: Agency for Healthcare Research and Quality. February 18, 2014;79:9214…
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psnet.ahrq.gov/issue/solicitation-written-comments-draft-national-action-plan-adverse-drug-event-prevention
October 21, 2016 - Government Resource
Solicitation for written comments on draft National Action Plan for Adverse Drug Event Prevention.
Citation Text:
Solicitation for written comments on draft National Action Plan for Adverse Drug Event Prevention. Federal Register. Washington, DC: Office of Disease…
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psnet.ahrq.gov/issue/communication-patterns-uk-emergency-department
June 17, 2010 - Study
Communication patterns in a UK emergency department.
Citation Text:
Woloshynowych M, Davis R, Brown R, et al. Communication patterns in a UK emergency department. Ann Emerg Med. 2007;50(4):407-13.
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psnet.ahrq.gov/issue/sounding-alarm-nurses-organizations-work-address-alarm-fatigue
July 19, 2017 - Newspaper/Magazine Article
Sounding the alarm. Nurses, organizations work to address alarm fatigue.
Citation Text:
Trossman S. Sounding the alarm. Nurses, organizations work to address alarm fatigue. Am Nurs. 2013;45(5):1, 6-7.
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psnet.ahrq.gov/issue/reducing-adverse-drug-events-related-opioids-implementation-guide
January 26, 2022 - Toolkit
Reducing Adverse Drug Events Related to Opioids Implementation Guide.
Citation Text:
Reducing Adverse Drug Events Related to Opioids Implementation Guide. Frederickson TW. Gordon DB, De Pinto M, et al. Philadelphia, PA: Society of Hospital Medicine; 2015.
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psnet.ahrq.gov/issue/2011-john-m-eisenberg-patient-safety-and-quality-awards
November 19, 2018 - Award Recipient
2011 John M. Eisenberg Patient Safety and Quality Awards.
Citation Text:
2011 John M. Eisenberg Patient Safety and Quality Awards. Jt Comm J Qual Patient Saf. 2012;38(7):289-327.
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psnet.ahrq.gov/issue/post-operative-mortality-missed-care-and-nurse-staffing-nine-countries-cross-sectional-study
December 12, 2014 - June 22, 2022
Factors associated with missed nursing care and nurse-assessed quality
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psnet.ahrq.gov/issue/safety-attitudes-questionnaire-psychometric-properties-benchmarking-data-and-emerging
June 16, 2011 - nursing homes: variance of six patient safety climate factor scores across nursing homes and wards—assessed
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psnet.ahrq.gov/issue/why-patient-summaries-electronic-health-records-do-not-provide-cognitive-support-necessary
January 18, 2013 - January 18, 2013
The effect of hospital electronic health record adoption on nurse-assessed