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  1. Impact of the Care Quality Commission on Provider Performance: Room for Improvement? | PSNet

    psnet.ahrq.gov/issue/impact-care-quality-commission-provider-performance-room-improvement
    November 18, 2015 - Book/Report Impact of the Care Quality Commission on Provider Performance: Room for Improvement? Citation Text: Impact of the Care Quality Commission on Provider Performance: Room for Improvement? Smithson R, Richardson E, Roberts J, et al. The King's Fund, Alliance Manchester Business S…

  2. Towards an organization with a memory: exploring the organizational generation of adverse events in health care. | PSNet

    psnet.ahrq.gov/issue/towards-organization-memory-exploring-organizational-generation-adverse-events-health-care
    February 22, 2010 - Commentary Towards an organization with a memory: exploring the organizational generation of adverse events in health care. Citation Text: Smith D, Toft B. Towards an organization with a memory: exploring the organizational generation of adverse events in health care. Health Serv Manag…

  3. Safety huddles in the PACU: when a patient self-medicates. | PSNet

    psnet.ahrq.gov/issue/safety-huddles-pacu-when-patient-self-medicates
    December 14, 2016 - Commentary Safety huddles in the PACU: when a patient self-medicates. Citation Text: Setaro J, Connolly M. Safety huddles in the PACU: when a patient self-medicates. J Perianesth Nurs. 2011;26(2):96-102. doi:10.1016/j.jopan.2011.01.010. Copy Citation Format: DOI Google Sc…

  4. Hand-off Communications. | PSNet

    psnet.ahrq.gov/issue/hand-communications
    January 04, 2017 - Multi-use Website Hand-off Communications. Citation Text: DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Copy Citation Format: Google Scholar P…

  5. Using an interactive voice response system to improve patient safety following hospital discharge. | PSNet

    psnet.ahrq.gov/issue/using-interactive-voice-response-system-improve-patient-safety-following-hospital-discharge
    February 01, 2017 - Study Using an interactive voice response system to improve patient safety following hospital discharge. Citation Text: Forster AJ, van Walraven C. Using an interactive voice response system to improve patient safety following hospital discharge. J Eval Clin Pract. 2007;13(3):346-51. …

  6. Measuring handoff quality in labor and delivery: development, validation, and application of the Coordination of Handoff Effectiveness Questionnaire (CHEQ). | PSNet

    psnet.ahrq.gov/issue/measuring-handoff-quality-labor-and-delivery-development-validation-and-application
    January 03, 2017 - Study Measuring handoff quality in labor and delivery: development, validation, and application of the Coordination of Handoff Effectiveness Questionnaire (CHEQ). Citation Text: Block M, Ehrenworth JF, Cuce VM, et al. Measuring handoff quality in labor and delivery: development, valid…

  7. Effectiveness of the surgical safety checklist in a high standard care environment. | PSNet

    psnet.ahrq.gov/issue/effectiveness-surgical-safety-checklist-high-standard-care-environment
    July 06, 2012 - Study Effectiveness of the surgical safety checklist in a high standard care environment. Citation Text: Lübbeke A, Hovaguimian F, Wickboldt N, et al. Effectiveness of the surgical safety checklist in a high standard care environment. Med Care. 2013;51(5):425-9. doi:10.1097/MLR.0b013e31…

  8. Disclosure of medical error: policies and practice. | PSNet

    psnet.ahrq.gov/issue/disclosure-medical-error-policies-and-practice
    June 30, 2011 - Commentary Disclosure of medical error: policies and practice. Citation Text: Kalra J, Massey L, Mulla A. Disclosure of medical error: policies and practice. J R Soc Med. 2005;98(7):307-309. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML End…

  9. Cutting-edge efforts in surgical patient safety. | PSNet

    psnet.ahrq.gov/issue/cutting-edge-efforts-surgical-patient-safety
    August 02, 2015 - Commentary Cutting-edge efforts in surgical patient safety. Citation Text: Varghese TK, Ghaferi AA. Cutting-edge Efforts in Surgical Patient Safety. JAMA Surg. 2017;152(8):719-720. doi:10.1001/jamasurg.2017.0858. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNot…

  10. Reducing preventable medication safety events by recognizing renal risk. | PSNet

    psnet.ahrq.gov/issue/reducing-preventable-medication-safety-events-recognizing-renal-risk
    June 27, 2011 - Study Reducing preventable medication safety events by recognizing renal risk. Citation Text: Fields W, Tedeschi C, Foltz J, et al. Reducing preventable medication safety events by recognizing renal risk. Clin Nurse Spec. 2008;22(2):73-8; quiz 79-80. doi:10.1097/01.NUR.0000311795.69476…

  11. Safety-I, Safety-II and burnout: how complexity science can help clinician wellness. | PSNet

    psnet.ahrq.gov/issue/safety-i-safety-ii-and-burnout-how-complexity-science-can-help-clinician-wellness
    December 20, 2017 - Review Safety-I, Safety-II and burnout: how complexity science can help clinician wellness. Citation Text: Smaggus A. Safety-I, Safety-II and burnout: how complexity science can help clinician wellness. BMJ Qual Saf. 2019;28(8):667-671. doi:10.1136/bmjqs-2018-009147. Copy Citation …

  12. Safe and equitable pediatric clinical use of AI. | PSNet

    psnet.ahrq.gov/issue/safe-and-equitable-pediatric-clinical-use-ai
    February 26, 2025 - Commentary Safe and equitable pediatric clinical use of AI. Citation Text: Handley JL, Lehmann CU, Ratwani RM. Safe and equitable pediatric clinical use of AI. JAMA Pediatr. 2024;178(7):637-638. doi:10.1001/jamapediatrics.2024.0897. Copy Citation Format: DOI Google Scholar …

  13. The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU. | PSNet

    psnet.ahrq.gov/issue/safety-attitudes-questionnaire-tool-benchmarking-safety-culture-nicu
    March 02, 2012 - Study The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU. Citation Text: Profit J, Etchegaray J, Petersen L, et al. The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU. Arch Dis Child Fetal Neonatal Ed. 2012;97(…

  14. Identifying quality markers of a safe surgical ward: an interview study of patients, clinical staff, and administrators. | PSNet

    psnet.ahrq.gov/issue/identifying-quality-markers-safe-surgical-ward-interview-study-patients-clinical-staff-and
    June 17, 2015 - Study Identifying quality markers of a safe surgical ward: an interview study of patients, clinical staff, and administrators. Citation Text: Hassen Y, Singh P, Pucher PH, et al. Identifying quality markers of a safe surgical ward: An interview study of patients, clinical staff, and admi…

  15. Improving Papanicolaou test quality and reducing medical errors by using Toyota production system methods. | PSNet

    psnet.ahrq.gov/issue/improving-papanicolaou-test-quality-and-reducing-medical-errors-using-toyota-production
    April 08, 2008 - Study Improving Papanicolaou test quality and reducing medical errors by using Toyota production system methods. Citation Text: Raab SS, Andrew-JaJa C, Condel JL, et al. Improving Papanicolaou test quality and reducing medical errors by using Toyota production system methods. Am J Obst…

  16. Escape Fire: Lessons for the Future of Health Care. | PSNet

    psnet.ahrq.gov/issue/escape-fire-lessons-future-health-care
    July 05, 2008 - Book/Report Classic Escape Fire: Lessons for the Future of Health Care. Citation Text: Escape Fire: Lessons for the Future of Health Care. Berwick DM. Washington DC: Commonwealth Fund; 2002. Copy Citation Save Save to your library P…

  17. An institution-wide handoff task force to standardise and improve physician handoffs. | PSNet

    psnet.ahrq.gov/issue/institution-wide-handoff-task-force-standardise-and-improve-physician-handoffs
    January 07, 2015 - Study An institution-wide handoff task force to standardise and improve physician handoffs. Citation Text: Horwitz LI, Schuster KM, Thung SF, et al. An institution-wide handoff task force to standardise and improve physician handoffs. BMJ Qual Saf. 2012;21(10):863-71. Copy Citation …

  18. 'Balancing risk, that is my life': The politics of risk in a hospital operating theatre department. | PSNet

    psnet.ahrq.gov/issue/balancing-risk-my-life-politics-risk-hospital-operating-theatre-department
    July 20, 2010 - Commentary 'Balancing risk, that is my life': The politics of risk in a hospital operating theatre department. Citation Text: McDonald R, Waring J, Harrison S. ‘Balancing risk, that is my life’: The politics of risk in a hospital operating theatre department. Health Risk Soc. 2005;7(4)…

  19. New technology, new errors: how to prime an upgrade of an insulin infusion pump. | PSNet

    psnet.ahrq.gov/issue/new-technology-new-errors-how-prime-upgrade-insulin-infusion-pump
    July 14, 2010 - Commentary New technology, new errors: how to prime an upgrade of an insulin infusion pump. Citation Text: Rule AM, Drincic A, Galt K. New technology, new errors: how to prime an upgrade of an insulin infusion pump. Jt Comm J Qual Patient Saf. 2007;33(3):155-62. Copy Citation Forma…

  20. A multicenter trial of aviation-style training for surgical teams. | PSNet

    psnet.ahrq.gov/issue/multicenter-trial-aviation-style-training-surgical-teams
    October 03, 2011 - Study A multicenter trial of aviation-style training for surgical teams. Citation Text: Catchpole K, Dale TJ, Hirst G, et al. A multicenter trial of aviation-style training for surgical teams. J Patient Saf. 2010;6(3):180-6. doi:10.1097/PTS.0b013e3181f100ea. Copy Citation Format…
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