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  1. To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. | PSNet

    psnet.ahrq.gov/issue/err-system-comparison-methodologies-investigation-adverse-outcomes-healthcare
    January 26, 2022 - Commentary To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. Citation Text: Isherwood P, Waterson P. To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. J Patient Saf Risk Manag. 2…

  2. Communicating uncertainty: a narrative review and framework for future research. | PSNet

    psnet.ahrq.gov/issue/communicating-uncertainty-narrative-review-and-framework-future-research
    February 24, 2021 - Review Communicating uncertainty: a narrative review and framework for future research. Citation Text: Simpkin AL, Armstrong KA. Communicating uncertainty: a narrative review and framework for future research. J Gen Intern Med. 2019;34(11):2586-2591. doi:10.1007/s11606-019-04860-8. Cop…

  3. The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technologies. | PSNet

    psnet.ahrq.gov/issue/confused-and-bewildered-hospital-adverse-event-discovery-pay-performance-and-big-data-tools
    September 23, 2020 - Commentary The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technologies. Citation Text: Furrow BR. The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technolog…

  4. Patient safety culture in primary care: developing a theoretical framework for practical use. | PSNet

    psnet.ahrq.gov/issue/patient-safety-culture-primary-care-developing-theoretical-framework-practical-use
    September 06, 2017 - Study Patient safety culture in primary care: developing a theoretical framework for practical use. Citation Text: Kirk S, Parker D, Claridge T, et al. Patient safety culture in primary care: developing a theoretical framework for practical use. Qual Saf Health Care. 2007;16(4):313-20.…

  5. Integrating systemic accident analysis into patient safety incident investigation practices. | PSNet

    psnet.ahrq.gov/issue/integrating-systemic-accident-analysis-patient-safety-incident-investigation-practices
    October 27, 2021 - Study Integrating systemic accident analysis into patient safety incident investigation practices. Citation Text: Canham A, Jun GT, Waterson P, et al. Integrating systemic accident analysis into patient safety incident investigation practices. Appl Ergon. 2018;72:1-9. doi:10.1016/j.aperg…

  6. A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions. | PSNet

    psnet.ahrq.gov/issue/prospective-hazard-and-improvement-analytic-approach-predicting-effectiveness-medication
    December 04, 2013 - Study A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions. Citation Text: Karnon J, McIntosh A, Dean JE, et al. A prospective hazard and improvement analytic approach to predicting the effectiveness of medication erro…

  7. The power of written word: reflection reduces errors of omission. | PSNet

    psnet.ahrq.gov/issue/power-written-word-reflection-reduces-errors-omission
    April 24, 2018 - Study The power of written word: reflection reduces errors of omission. Citation Text: Rao A, Heidemann LA, Hartley S, et al. The power of written word: reflection reduces errors of omission. Clin Teach. 2024;21(1):e13630. doi:10.1111/tct.13630. Copy Citation Format: DOI Go…

  8. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills. | PSNet

    psnet.ahrq.gov/issue/key-performance-outcomes-patient-safety-curricula-root-cause-analysis-failure-mode-and
    July 23, 2010 - Commentary Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills. Citation Text: Fassett WE. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects …

  9. Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety. | PSNet

    psnet.ahrq.gov/issue/commissioning-simulations-test-new-healthcare-facilities-proactive-and-innovative-approach
    September 30, 2020 - Commentary Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety. Citation Text: Kaba A, Barnes S. Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system …

  10. Performance characteristics of a methodology to quantify adverse events over time in hospitalized patients. | PSNet

    psnet.ahrq.gov/issue/performance-characteristics-methodology-quantify-adverse-events-over-time-hospitalized
    December 01, 2010 - Study Performance characteristics of a methodology to quantify adverse events over time in hospitalized patients. Citation Text: Sharek PJ, Parry G, Goldmann DA, et al. Performance characteristics of a methodology to quantify adverse events over time in hospitalized patients. Health Se…

  11. The impact of power on health care team performance and patient safety: a review of the literature. | PSNet

    psnet.ahrq.gov/issue/impact-power-health-care-team-performance-and-patient-safety-review-literature
    February 01, 2023 - Review The impact of power on health care team performance and patient safety: a review of the literature. Citation Text: Stevens EL, Hulme A, Salmon PM. The impact of power on health care team performance and patient safety: a review of the literature. Ergonomics. 2021;64(8):1072-1090. …

  12. Augmenting health care failure modes and effects analysis with simulation. | PSNet

    psnet.ahrq.gov/issue/augmenting-health-care-failure-modes-and-effects-analysis-simulation
    December 18, 2024 - Study Augmenting health care failure modes and effects analysis with simulation. Citation Text: Nielsen DS, Dieckmann P, Mohr M, et al. Augmenting health care failure modes and effects analysis with simulation. Simul Healthc. 2014;9(1):48-55. doi:10.1097/SIH.0b013e3182a3defd. Copy Cit…

  13. Diagnostic reliability in teledermatology: a systematic review and a meta-analysis. | PSNet

    psnet.ahrq.gov/issue/diagnostic-reliability-teledermatology-systematic-review-and-meta-analysis
    September 23, 2020 - Review Diagnostic reliability in teledermatology: a systematic review and a meta-analysis. Citation Text: Bourkas AN, Barone N, Bourkas MEC, et al. Diagnostic reliability in teledermatology: a systematic review and a meta-analysis. BMJ Open. 2023;13(8):e068207. doi:10.1136/bmjopen-2022-0…

  14. Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology ward. | PSNet

    psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-useful-proactive-risk-analysis-pediatric
    June 13, 2011 - Study Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology ward. Citation Text: van Tilburg CM, Leistikow IP, Rademaker CMA, et al. Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology w…

  15. The effect of the fit between organizational culture and structure on medication errors in medical group practices. | PSNet

    psnet.ahrq.gov/issue/effect-fit-between-organizational-culture-and-structure-medication-errors-medical-group
    June 30, 2009 - Study The effect of the fit between organizational culture and structure on medication errors in medical group practices. Citation Text: Kaissi A, Kralewski J, Dowd B, et al. The effect of the fit between organizational culture and structure on medication errors in medical group practi…

  16. Use of a safety climate questionnaire in UK health care: factor structure, reliability and usability. | PSNet

    psnet.ahrq.gov/issue/use-safety-climate-questionnaire-uk-health-care-factor-structure-reliability-and-usability
    June 15, 2011 - Study Use of a safety climate questionnaire in UK health care: factor structure, reliability and usability. Citation Text: Hutchinson A, Cooper KL, Dean JE, et al. Use of a safety climate questionnaire in UK health care: factor structure, reliability and usability. Qual Saf Health Care…

  17. Patient safety and ethical implications of healthcare sick leave policies in the pandemic era. | PSNet

    psnet.ahrq.gov/issue/patient-safety-and-ethical-implications-healthcare-sick-leave-policies-pandemic-era
    September 16, 2020 - Commentary Patient safety and ethical implications of healthcare sick leave policies in the pandemic era. Citation Text: Preston-Suni K, Celedon MA, Cordasco KM. Patient safety and ethical implications of healthcare sick leave policies in the pandemic era. Jt Comm J Qual Patient Saf. 202…

  18. Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report. | PSNet

    psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2009-comparative-database-report
    November 30, 2016 - Book/Report Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report. Citation Text: Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report. Sorra J, Famloaro T, Dyer N, Nelson D, Khanna K. Rockville, MD: Agency for Healthcare Research and Qualit…

  19. A structured judgement method to enhance mortality case note review: development and evaluation. | PSNet

    psnet.ahrq.gov/issue/structured-judgement-method-enhance-mortality-case-note-review-development-and-evaluation
    May 27, 2011 - Study A structured judgement method to enhance mortality case note review: development and evaluation. Citation Text: Hutchinson A, Coster JE, Cooper KL, et al. A structured judgement method to enhance mortality case note review: development and evaluation. BMJ Qual Saf. 2013;22(12). do…

  20. Patient safety informatics: meeting the challenges of emerging digital health. | PSNet

    psnet.ahrq.gov/issue/patient-safety-informatics-meeting-challenges-emerging-digital-health
    June 08, 2022 - Commentary Patient safety informatics: meeting the challenges of emerging digital health. Citation Text: McInerney C, Benn J, Dowding D, et al. Patient safety informatics: meeting the challenges of emerging digital health. Stud Health Technol Inform. 2022;290:364-368. doi:10.3233/shti220…
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