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  1. Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series. | PSNet

    psnet.ahrq.gov/issue/final-report-prioritization-patient-safety-practices-new-rapid-review-or-rapid-response
    December 21, 2022 - Book/Report Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series. Citation Text: Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer …

  2. Review of medication errors that are new or likely to occur more frequently with electronic medication management systems. | PSNet

    psnet.ahrq.gov/issue/review-medication-errors-are-new-or-likely-occur-more-frequently-electronic-medication
    August 18, 2021 - Study Review of medication errors that are new or likely to occur more frequently with electronic medication management systems. Citation Text: Van de Vreede M, McGrath A, de Clifford J. Review of medication errors that are new or likely to occur more frequently with electronic medicatio…

  3. Risk perception on the labour ward: a mixed methods study. | PSNet

    psnet.ahrq.gov/issue/risk-perception-labour-ward-mixed-methods-study
    June 08, 2022 - Study Risk perception on the labour ward: a mixed methods study. Citation Text: McCarthy C, Meaney S, Rochford M, et al. Risk perception on the labour ward: a mixed methods study. J Patient Saf Risk Manag. 2021;26(2):56-63. doi:10.1177/25160435211002428. Copy Citation Format: …

  4. In search of an international multidimensional action plan for second victim support: a narrative review. | PSNet

    psnet.ahrq.gov/issue/search-international-multidimensional-action-plan-second-victim-support-narrative-review
    February 15, 2023 - Review In search of an international multidimensional action plan for second victim support: a narrative review. Citation Text: Seys D, Panella M, Russotto S, et al. In search of an international multidimensional action plan for second victim support: a narrative review. BMC Health Serv …

  5. Longitudinal analysis of culture of patient safety survey results in surgical departments. | PSNet

    psnet.ahrq.gov/issue/longitudinal-analysis-culture-patient-safety-survey-results-surgical-departments
    October 12, 2022 - Study Longitudinal analysis of culture of patient safety survey results in surgical departments. Citation Text: Butler LR, Lashani S, Mitchell C, et al. Longitudinal analysis of culture of patient safety survey results in surgical departments. Front Health Serv. 2024;4:1419248. doi:10.33…

  6. Application of a digital quality measure for cancer diagnosis in Epic Cosmos. | PSNet

    psnet.ahrq.gov/issue/application-digital-quality-measure-cancer-diagnosis-epic-cosmos
    November 13, 2024 - Study Application of a digital quality measure for cancer diagnosis in Epic Cosmos. Citation Text: Zimolzak AJ, Khan SP, Singh H, et al. Application of a digital quality measure for cancer diagnosis in Epic Cosmos. J Am Med Inform Assoc. 2025;32(1):227-229. doi:10.1093/jamia/ocae253. C…

  7. A systematic review on the evidence of misdiagnosis in dementia and its impact on accessing dementia care. | PSNet

    psnet.ahrq.gov/issue/systematic-review-evidence-misdiagnosis-dementia-and-its-impact-accessing-dementia-care
    December 02, 2020 - Review A systematic review on the evidence of misdiagnosis in dementia and its impact on accessing dementia care. Citation Text: Giebel C, Silva‐Ribeiro W, Watson J, et al. A systematic review on the evidence of misdiagnosis in dementia and its impact on accessing dementia care. Int J Ge…

  8. Improving patient safety in intensive care units in Michigan. | PSNet

    psnet.ahrq.gov/issue/improving-patient-safety-intensive-care-units-michigan
    February 17, 2011 - Study Classic Improving patient safety in intensive care units in Michigan. Citation Text: Pronovost P, Berenholtz SM, Goeschel CA, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23(2):207-212. doi:10.1016/j.jcrc.2007.09…

  9. Interprofessional collaboration among care professionals in obstetrical care: are perceptions aligned? | PSNet

    psnet.ahrq.gov/issue/interprofessional-collaboration-among-care-professionals-obstetrical-care-are-perceptions
    May 28, 2014 - Study Interprofessional collaboration among care professionals in obstetrical care: are perceptions aligned? Citation Text: Romijn A, Teunissen PW, de Bruijne M, et al. Interprofessional collaboration among care professionals in obstetrical care: are perceptions aligned? BMJ Qual Saf. 20…

  10. National Partnership for Maternal Safety: consensus bundle on support after a severe maternal event. | PSNet

    psnet.ahrq.gov/issue/national-partnership-maternal-safety-consensus-bundle-support-after-severe-maternal-event
    December 15, 2021 - Organizational Policy/Guidelines National Partnership for Maternal Safety: consensus bundle on support after a severe maternal event. Citation Text: Morton CH, Hall MF, Shaefer SJM, et al. National Partnership for Maternal Safety: Consensus Bundle on Support After a Severe Maternal Event…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36093/psn-pdf
    August 09, 2007 - Hospitals combat errors at the 'hand-off.' August 9, 2007 Landro L. https://psnet.ahrq.gov/issue/hospitals-combat-errors-hand This article reports on communication interventions such as SBAR (Situation-Background-Assessment- Recommendation) that make patient hand-offs more reliable. https://psnet.ahrq.gov/issue/h…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42391/psn-pdf
    June 26, 2013 - Patient Notification Toolkit. June 26, 2013 Centers for Disease Control and Prevention; CDC. https://psnet.ahrq.gov/issue/patient-notification-toolkit This toolkit provides guidance and resources to help organizations inform patients about infection control lapses. https://psnet.ahrq.gov/issue/patient-notificatio…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36357/psn-pdf
    December 19, 2009 - Error reporting in organizations. December 19, 2009 Zhao B; Olivera F. Acad Manag Rev. 2006;31(4):1012-1030. https://psnet.ahrq.gov/issue/error-reporting-organizations The authors provide a framework for individual error reporting behavior that follows three phases: error detection, situation assessment, and choic…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35765/psn-pdf
    September 14, 2008 - Manchester Patient Safety Framework (MaPSaF). September 14, 2008 Manchester, UK: University of Manchester; 2006. https://psnet.ahrq.gov/issue/manchester-patient-safety-framework-mapsaf This tool was developed to help National Health Service organizations assess their progress in implementing and sustaining a safet…

  15. Preventing PICC Complications: Whose Line Is It? | PSNet

    psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
    October 01, 2017 - Preventing PICC Complications: Whose Line Is It? Citation Text: Moureau N. Preventing PICC Complications: Whose Line Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibT…

  16. Inflicting Confusion | PSNet

    psnet.ahrq.gov/web-mm/inflicting-confusion
    August 04, 2021 - Inflicting Confusion Citation Text: Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …

  17. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization | PSNet

    psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
    September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization Citation Text: Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Ci…

  18. Medical Devices in the "Wild" | PSNet

    psnet.ahrq.gov/web-mm/medical-devices-wild
    March 27, 2024 - Medical Devices in the "Wild" Citation Text: Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

  19. CVC Removal: A Procedure Like Any Other | PSNet

    psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
    October 01, 2018 - CVC Removal: A Procedure Like Any Other Citation Text: Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846770/psn-pdf
    March 29, 2023 - Procedure Complications – Who is Responsible for Follow up? March 29, 2023 Chalupsky M, Wei H, Marquet E. Procedure Complications – Who is Responsible for Follow up? PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow The Case A 74-year-old man with newly diagnose…
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