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  1. Intraoperative communications between pathologists and surgeons: do we understand each other? | PSNet

    psnet.ahrq.gov/issue/intraoperative-communications-between-pathologists-and-surgeons-do-we-understand-each-other
    June 28, 2023 - Study Intraoperative communications between pathologists and surgeons: do we understand each other? Citation Text: Wiggett A, Fischer G. Intraoperative communications between pathologists and surgeons: do we understand each other? Arch Pathol Lab Med. 2023;147(8):933-939. doi:10.5858/arp…

  2. Secure messaging use and wrong-patient ordering errors among inpatient clinicians. | PSNet

    psnet.ahrq.gov/issue/secure-messaging-use-and-wrong-patient-ordering-errors-among-inpatient-clinicians
    July 20, 2022 - Study Secure messaging use and wrong-patient ordering errors among inpatient clinicians. Citation Text: Lou SS, Lew D, Xia L, et al. Secure messaging use and wrong-patient ordering errors among inpatient clinicians. JAMA Netw Open. 2024;7(12):e2447797. doi:10.1001/jamanetworkopen.2024.47…

  3. Pain as the neglected patient safety concern: five years on. | PSNet

    psnet.ahrq.gov/issue/pain-neglected-patient-safety-concern-five-years
    July 31, 2019 - Commentary Pain as the neglected patient safety concern: five years on. Citation Text: Twycross A, Forgeron P, Chorne J, et al. Pain as the neglected patient safety concern: Five years on. J Child Health Care. 2016;20(4):537-541. doi:10.1177/1367493516643422. Copy Citation Format: …

  4. A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes. | PSNet

    psnet.ahrq.gov/issue/systematic-review-unintended-consequences-clinical-interventions-reduce-adverse-outcomes
    November 15, 2023 - Review A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes. Citation Text: Manojlovich M, Lee S, Lauseng D. A Systematic Review of the Unintended Consequences of Clinical Interventions to Reduce Adverse Outcomes. J Patient Saf. 2016;12(…

  5. The effects of bar-coding technology on medication errors: a systematic literature review. | PSNet

    psnet.ahrq.gov/issue/effects-bar-coding-technology-medication-errors-systematic-literature-review
    March 20, 2024 - Review The effects of bar-coding technology on medication errors: a systematic literature review. Citation Text: Hutton K, Ding Q, Wellman G. The Effects of Bar-coding Technology on Medication Errors: A Systematic Literature Review. J Patient Saf. 2021;17(3):e192-e206. doi:10.1097/PTS.00…

  6. Sustained improvement in neonatal intensive care unit safety attitudes after teamwork training. | PSNet

    psnet.ahrq.gov/issue/sustained-improvement-neonatal-intensive-care-unit-safety-attitudes-after-teamwork-training
    March 26, 2015 - Study Sustained improvement in neonatal intensive care unit safety attitudes after teamwork training. Citation Text: Murphy T, Laptook A, Bender J. Sustained Improvement in Neonatal Intensive Care Unit Safety Attitudes After Teamwork Training. J Patient Saf. 2018;14(3):174-180. doi:10.10…

  7. Preventing mistransfusions: an evaluation of institutional knowledge and a response. | PSNet

    psnet.ahrq.gov/issue/preventing-mistransfusions-evaluation-institutional-knowledge-and-response
    June 06, 2018 - Study Preventing mistransfusions: an evaluation of institutional knowledge and a response. Citation Text: MacDougall N, Dong F, Broussard L, et al. Preventing Mistransfusions: An Evaluation of Institutional Knowledge and a Response. Anesth Analg. 2018;126(1):247-251. doi:10.1213/ANE.0000…

  8. Perceived value of ward-based pharmacists from the perspective of physicians and nurses. | PSNet

    psnet.ahrq.gov/issue/perceived-value-ward-based-pharmacists-perspective-physicians-and-nurses
    February 15, 2011 - Study Perceived value of ward-based pharmacists from the perspective of physicians and nurses. Citation Text: Gillespie U, Mörlin C, Hammarlund-Udenaes M, et al. Perceived value of ward-based pharmacists from the perspective of physicians and nurses. Int J Clin Pharm. 2012;34(1):127-35…

  9. 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 …

  10. 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 …

  11. Designing an abstraction instrument: lessons from efforts to validate the AHRQ Patient Safety Indicators. | PSNet

    psnet.ahrq.gov/issue/designing-abstraction-instrument-lessons-efforts-validate-ahrq-patient-safety-indicators
    January 13, 2010 - Commentary Designing an abstraction instrument: lessons from efforts to validate the AHRQ Patient Safety Indicators. Citation Text: Utter GH, Borzecki A, Rosen AK, et al. Designing an abstraction instrument: lessons from efforts to validate the AHRQ patient safety indicators. Jt Comm J Q…

  12. Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. | PSNet

    psnet.ahrq.gov/issue/hospital-incident-reporting-systems-do-not-capture-most-patient-harm
    September 20, 2011 - Book/Report Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. Citation Text: Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 201…

  13. Safety culture, safety climate, and safety performance in healthcare facilities: a systematic review. | PSNet

    psnet.ahrq.gov/issue/safety-culture-safety-climate-and-safety-performance-healthcare-facilities-systematic-review
    October 20, 2021 - Review Safety culture, safety climate, and safety performance in healthcare facilities: a systematic review. Citation Text: Noor Arzahan IS, Ismail Z, Yasin SM. Safety culture, safety climate, and safety performance in healthcare facilities: A systematic review. Safety Sci. 2022;147:1056…

  14. Variations by state in physician disciplinary actions by US medical licensure boards. | PSNet

    psnet.ahrq.gov/issue/variations-state-physician-disciplinary-actions-us-medical-licensure-boards
    March 12, 2025 - Study Variations by state in physician disciplinary actions by US medical licensure boards. Citation Text: Harris JA, Byhoff E. Variations by state in physician disciplinary actions by US medical licensure boards. BMJ Qual Saf. 2017;26(3):200-208. doi:10.1136/bmjqs-2015-004974. Copy Ci…

  15. 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 …

  16. 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…

  17. 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…

  18. SEIPS 3.0: human-centered design of the patient journey for patient safety. | PSNet

    psnet.ahrq.gov/issue/seips-30-human-centered-design-patient-journey-patient-safety
    September 11, 2019 - Review Classic SEIPS 3.0: human-centered design of the patient journey for patient safety. Citation Text: Carayon P, Wooldridge AR, Hoonakker P, et al. SEIPS 3.0: human-centered design of the patient journey for patient safety. App Ergon. 2020;84:103033. doi:10…

  19. A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and its meetings. | PSNet

    psnet.ahrq.gov/issue/practical-guide-failure-mode-and-effects-analysis-health-care-making-most-team-and-its
    March 04, 2015 - Commentary A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and its meetings. Citation Text: Ashley L, Armitage G, Neary M, et al. A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and its …

  20. 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…
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