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  1. Understanding complexity in a safety critical setting: a systems approach to medication administration. | PSNet

    psnet.ahrq.gov/issue/understanding-complexity-safety-critical-setting-systems-approach-medication-administration
    February 01, 2023 - Study Understanding complexity in a safety critical setting: a systems approach to medication administration. Citation Text: Stevens EL, Hulme A, Goode N, et al. Understanding complexity in a safety critical setting: a systems approach to medication administration. Appl Ergon. 2023;110:1…

  2. Expert consensus on currently accepted measures of harm. | PSNet

    psnet.ahrq.gov/issue/expert-consensus-currently-accepted-measures-harm
    January 25, 2023 - Commentary Expert consensus on currently accepted measures of harm. Citation Text: Logan MS, Myers LC, Salmasian H, et al. Expert consensus on currently accepted measures of harm. J Patient Saf. 2021;17(8):e1726-e1731. doi:10.1097/pts.0000000000000754. Copy Citation Format: …

  3. Morbidity and mortality conference in emergency medicine residencies and the culture of safety. | PSNet

    psnet.ahrq.gov/issue/morbidity-and-mortality-conference-emergency-medicine-residencies-and-culture-safety
    November 16, 2022 - Study Morbidity and mortality conference in emergency medicine residencies and the culture of safety. Citation Text: Aaronson E, Wittels KA, Nadel ES, et al. Morbidity and Mortality Conference in Emergency Medicine Residencies and the Culture of Safety. West J Emerg Med. 2015;16(6):810-7…

  4. Do clinician disruptive behaviors make an unsafe environment for patients? | PSNet

    psnet.ahrq.gov/issue/do-clinician-disruptive-behaviors-make-unsafe-environment-patients
    September 16, 2020 - Study Do clinician disruptive behaviors make an unsafe environment for patients? Citation Text: Dang D, Bae S-H, Karlowicz KA, et al. Do Clinician Disruptive Behaviors Make an Unsafe Environment for Patients? J Nurs Care Qual. 2016;31(2):115-123. doi:10.1097/NCQ.0000000000000150. Copy …

  5. Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand. | PSNet

    psnet.ahrq.gov/issue/case-34-2010-65-year-old-woman-incorrect-operation-left-hand
    March 13, 2013 - Commentary Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand. Citation Text: Ring DC, Herndon JH, Meyer GS. Case records of The Massachusetts General Hospital: Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand. N Engl J Med. 201…

  6. An invisible disability: communication, patient safety and dual sensory impairment in older persons. | PSNet

    psnet.ahrq.gov/issue/invisible-disability-communication-patient-safety-and-dual-sensory-impairment-older-persons
    July 01, 2019 - Commentary An invisible disability: communication, patient safety and dual sensory impairment in older persons. Citation Text: Dunsmore ME, Watharow A, Schneider J. An invisible disability: communication, patient safety and dual sensory impairment in older persons. J Adv Nurs. 2024;Epub …

  7. Safety of medication use in primary care. | PSNet

    psnet.ahrq.gov/issue/safety-medication-use-primary-care
    March 04, 2011 - Review Safety of medication use in primary care. Citation Text: Olaniyan JO, Ghaleb M, Dhillon S, et al. Safety of medication use in primary care. Int J Pharm Pract. 2015;23(1):3-20. doi:10.1111/ijpp.12120. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 X…

  8. Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. | PSNet

    psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-fiscal-2021
    October 12, 2022 - Book/Report Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. Citation Text: Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. Washington, DC: Veterans Affairs Office of Inspector General; 2…

  9. Grand rounds in methodology: key considerations for implementing machine learning solutions in quality improvement initiatives. | PSNet

    psnet.ahrq.gov/issue/grand-rounds-methodology-key-considerations-implementing-machine-learning-solutions-quality
    July 26, 2023 - Commentary Grand rounds in methodology: key considerations for implementing machine learning solutions in quality improvement initiatives. Citation Text: Verma AA, Trbovich PL, Mamdani MM, et al. Grand rounds in methodology: key considerations for implementing machine learning solutions …

  10. The patient is in: patient involvement strategies for diagnostic error mitigation. | PSNet

    psnet.ahrq.gov/issue/patient-patient-involvement-strategies-diagnostic-error-mitigation
    April 24, 2018 - Review The patient is in: patient involvement strategies for diagnostic error mitigation. Citation Text: McDonald KM, Bryce CL, Graber ML. The patient is in: patient involvement strategies for diagnostic error mitigation. BMJ Qual Saf. 2013;22 Suppl 2:ii33-ii39. doi:10.1136/bmjqs-2012-…

  11. Crossing the Global Quality Chasm: Improving Health Care Worldwide. | PSNet

    psnet.ahrq.gov/issue/crossing-global-quality-chasm-improving-health-care-worldwide
    June 15, 2011 - Book/Report Classic Crossing the Global Quality Chasm: Improving Health Care Worldwide. Citation Text: Crossing the Global Quality Chasm: Improving Health Care Worldwide. Committee on Improving the Quality of Health Care Globally. National Academies of Sciences,…

  12. Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions. | PSNet

    psnet.ahrq.gov/issue/patient-and-clinician-experiences-uncertainty-diagnostic-process-current-understanding-and
    March 11, 2020 - Commentary Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions. Citation Text: Meyer AND, Giardina TD, Khawaja L, et al. Patient and clinician experiences of uncertainty in the diagnostic process: current understanding a…

  13. Pay practices and safety organizing: evidence from hospital nursing units. | PSNet

    psnet.ahrq.gov/issue/pay-practices-and-safety-organizing-evidence-hospital-nursing-units
    December 21, 2017 - Study Pay practices and safety organizing: evidence from hospital nursing units. Citation Text: Conroy SA, Vogus TJ. Pay practices and safety organizing: evidence from hospital nursing units. Health Care Manage Rev. 2023;49(1):68-73. doi:10.1097/hmr.0000000000000392. Copy Citation …

  14. Improving medication-related safety for residents in nursing homes: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/improving-medication-related-safety-residents-nursing-homes-qualitative-study
    March 24, 2019 - Study Improving medication-related safety for residents in nursing homes: a qualitative study. Citation Text: Shieu B, Lee Y-W, Epps F, et al. Improving medication-related safety for residents in nursing homes: a qualitative study. J Gerontol Nurs. 2025;51(3):38-43. doi:10.3928/00989134-…

  15. The impact of adverse events on clinicians: what's in a name? | PSNet

    psnet.ahrq.gov/issue/impact-adverse-events-clinicians-whats-name
    March 25, 2020 - Review The impact of adverse events on clinicians: what's in a name? Citation Text: Wu AW, Shapiro J, Harrison R, et al. The Impact of Adverse Events on Clinicians: What's in a Name? J Patient Saf. 2020;16(1):65-72. doi:10.1097/PTS.0000000000000256. Copy Citation Format: DO…

  16. “I had no idea this happened”: electronic feedback on clinical reasoning for hospitalists. | PSNet

    psnet.ahrq.gov/issue/i-had-no-idea-happened-electronic-feedback-clinical-reasoning-hospitalists
    February 28, 2024 - Study “I had no idea this happened”: electronic feedback on clinical reasoning for hospitalists. Citation Text: Kotwal S, Udayappan KM, Kutheala N, et al. “I had no idea this happened”: electronic feedback on clinical reasoning for hospitalists. J Gen Intern Med. 2024;39(16):3271-3277. d…

  17. Health technology, quality and safety in a learning health system. | PSNet

    psnet.ahrq.gov/issue/health-technology-quality-and-safety-learning-health-system
    February 09, 2022 - Commentary Health technology, quality and safety in a learning health system. Citation Text: Borycki EM, Kushniruk AW. Health technology, quality and safety in a learning health system. Healthc Manage Forum. 2023;51(2):212-221. doi:10.1177/08404704221139383. Copy Citation Format: …

  18. Learning from errors and resilience. | PSNet

    psnet.ahrq.gov/issue/learning-errors-and-resilience
    December 18, 2019 - Review Learning from errors and resilience. Citation Text: Arnal-Velasco D, Heras-Hernando V. Learning from errors and resilience. Curr Opin Anaesthesiol. 2023;36(3):376-381. doi:10.1097/aco.0000000000001257. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML En…

  19. Education for the next frontier in patient safety: a longitudinal resident curriculum on diagnostic error. | PSNet

    psnet.ahrq.gov/issue/education-next-frontier-patient-safety-longitudinal-resident-curriculum-diagnostic-error
    January 16, 2019 - Commentary Education for the next frontier in patient safety: a longitudinal resident curriculum on diagnostic error. Citation Text: Ruedinger E, Olson M, Yee J, et al. Education for the Next Frontier in Patient Safety: A Longitudinal Resident Curriculum on Diagnostic Error. Am J Med Qua…

  20. The new diagnostic team. | PSNet

    psnet.ahrq.gov/issue/new-diagnostic-team
    July 19, 2023 - Commentary The new diagnostic team. Citation Text: Graber ML, Rusz D, Jones ML, et al. The new diagnostic team. Diagnosis (Berl). 2017;4(4):225-238. doi:10.1515/dx-2017-0022. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
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