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  1. Blink or think: can further reflection improve initial diagnostic impressions? | PSNet

    psnet.ahrq.gov/issue/blink-or-think-can-further-reflection-improve-initial-diagnostic-impressions
    November 28, 2012 - Study Blink or think: can further reflection improve initial diagnostic impressions? Citation Text: Hess BJ, Lipner RS, Thompson V, et al. Blink or think: can further reflection improve initial diagnostic impressions? Acad Med. 2015;90(1):112-118. doi:10.1097/ACM.0000000000000550. Copy…

  2. The many faces of error disclosure: a common set of elements and a definition. | PSNet

    psnet.ahrq.gov/issue/many-faces-error-disclosure-common-set-elements-and-definition
    December 16, 2009 - Study Classic The many faces of error disclosure: a common set of elements and a definition. Citation Text: Fein SP, Hilborne LH, Spiritus EM, et al. The many faces of error disclosure: a common set of elements and a definition. J Gen Intern Med. 2007;22(6):75…

  3. Misunderstanding of prescription drug warning labels among patients with low literacy. | PSNet

    psnet.ahrq.gov/issue/misunderstanding-prescription-drug-warning-labels-among-patients-low-literacy
    February 28, 2011 - Study Misunderstanding of prescription drug warning labels among patients with low literacy. Citation Text: Wolf MS, Davis TC, Tilson HH, et al. Misunderstanding of prescription drug warning labels among patients with low literacy. Am J Health Syst Pharm. 2006;63(11):1048-55. Copy Ci…

  4. Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality. | PSNet

    psnet.ahrq.gov/issue/resilience-and-regulation-odd-couple-consequences-safety-ii-governmental-regulation
    October 06, 2021 - Commentary Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality. Citation Text: Leistikow I, Bal RA. Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality. BMJ Q…

  5. Applying lessons from social psychology to transform the culture of error disclosure. | PSNet

    psnet.ahrq.gov/issue/applying-lessons-social-psychology-transform-culture-error-disclosure
    March 20, 2024 - Commentary Applying lessons from social psychology to transform the culture of error disclosure. Citation Text: Han J, LaMarra D, Vapiwala N. Applying lessons from social psychology to transform the culture of error disclosure. Med Educ. 2017;51(10):996-1001. doi:10.1111/medu.13345. Co…

  6. Hospice diagnosis: polypharmacy—a teachable moment. | PSNet

    psnet.ahrq.gov/issue/hospice-diagnosis-polypharmacy-teachable-moment
    April 24, 2018 - Commentary Hospice diagnosis: polypharmacy—a teachable moment. Citation Text: Larson CK, Kao H. Hospice Diagnosis: Polypharmacy: A Teachable Moment. JAMA Intern Med. 2015;175(11):1750-1751. doi:10.1001/jamainternmed.2015.5253. Copy Citation Format: DOI Google Scholar PubMed…

  7. Improving the safety of medication administration using an interactive CD-ROM program. | PSNet

    psnet.ahrq.gov/issue/improving-safety-medication-administration-using-interactive-cd-rom-program
    February 15, 2011 - Commentary Improving the safety of medication administration using an interactive CD-ROM program. Citation Text: Schneider PJ, Pedersen CA, Montanya KR, et al. Improving the safety of medication administration using an interactive CD-ROM program. Am J Health Syst Pharm. 2006;63(1):59-6…

  8. Community Health Systems’ ongoing journey to zero preventable harm. | PSNet

    psnet.ahrq.gov/issue/community-health-systems-ongoing-journey-zero-preventable-harm
    July 29, 2020 - Commentary Community Health Systems’ ongoing journey to zero preventable harm. Citation Text: Simon LT, Van Buren T. Community Health Systems’ ongoing journey to zero preventable harm. NEJM Catal Innov Care Deliv. 2023;4(12). doi:10.1056/cat.23.0250. Copy Citation Format: D…

  9. Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. | PSNet

    psnet.ahrq.gov/issue/root-cause-analysis-reported-patient-falls-ors-veterans-health-administration
    January 17, 2019 - Commentary Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. Citation Text: Soncrant CM, Warner LJ, Neily J, et al. Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration. AORN J. 2018;108(4):386-397. doi:10.10…

  10. Errors in ABO labeling of deceased donor kidneys: case reports and approach to ensuring patient safety. | PSNet

    psnet.ahrq.gov/issue/errors-abo-labeling-deceased-donor-kidneys-case-reports-and-approach-ensuring-patient-safety
    June 09, 2021 - Study Errors in ABO labeling of deceased donor kidneys: case reports and approach to ensuring patient safety. Citation Text: Friedman AL, Lee KC, Lee GD. Errors in ABO Labeling of Deceased Donor Kidneys: Case Reports and Approach to Ensuring Patient Safety. American Journal of Transpla…

  11. Applying requisite imagination to safeguard electronic health record transitions. | PSNet

    psnet.ahrq.gov/issue/applying-requisite-imagination-safeguard-electronic-health-record-transitions
    August 25, 2021 - Commentary Applying requisite imagination to safeguard electronic health record transitions. Citation Text: Sittig DF, Lakhani P, Singh H. Applying requisite imagination to safeguard electronic health record transitions. J Am Med Inform Assoc. 2022;29(5):1014-1018. doi:10.1093/jamia/ocab…

  12. "Plans are worthless, but planning is everything": advancing patient safety by better managing the paradox of planning versus adaptation. | PSNet

    psnet.ahrq.gov/issue/plans-are-worthless-planning-everything-advancing-patient-safety-better-managing-paradox
    September 23, 2020 - Commentary "Plans are worthless, but planning is everything": advancing patient safety by better managing the paradox of planning versus adaptation. Citation Text: Call RC, Espiritu SG, Barrows DA. “Plans are worthless, but planning is everything”: advancing patient safety by better mana…

  13. The Pursuing Excellence Collaborative: engaging first-year residents and fellows in patient safety event investigations. | PSNet

    psnet.ahrq.gov/issue/pursuing-excellence-collaborative-engaging-first-year-residents-and-fellows-patient-safety
    September 15, 2011 - Commentary The Pursuing Excellence Collaborative: engaging first-year residents and fellows in patient safety event investigations. Citation Text: Paull DE, Newton RC, Tess AV, et al. The Pursuing Excellence Collaborative: engaging first-year residents and fellows in patient safety event…

  14. Integrating the intensive care unit safety reporting system with existing incident reporting systems. | PSNet

    psnet.ahrq.gov/issue/integrating-intensive-care-unit-safety-reporting-system-existing-incident-reporting-systems
    January 12, 2011 - Study Integrating the intensive care unit safety reporting system with existing incident reporting systems. Citation Text: Thompson DA, Lubomski LH, Holzmueller CG, et al. Integrating the intensive care unit safety reporting system with existing incident reporting systems. Jt Comm J Qual…

  15. Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety. | PSNet

    psnet.ahrq.gov/issue/dissecting-communication-barriers-healthcare-path-enhancing-communication-resiliency
    July 12, 2023 - Commentary Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety. Citation Text: Guttman OT, Lazzara EH, Keebler JR, et al. Dissecting Communication Barriers in Healthcare: A Path to Enhancing Communication Resilien…

  16. Dashboards for visual display of patient safety data: a systematic review. | PSNet

    psnet.ahrq.gov/issue/dashboards-visual-display-patient-safety-data-systematic-review
    November 11, 2020 - Review Dashboards for visual display of patient safety data: a systematic review. Citation Text: Murphy DR, Savoy A, Satterly T, et al. Dashboards for visual display of patient safety data: a systematic review. BMJ Health Care Inform. 2021;28(1):e100437. doi:10.1136/bmjhci-2021-100437. …

  17. Developing health care organizations that pursue learning and exploration of diagnostic excellence: an action plan. | PSNet

    psnet.ahrq.gov/issue/developing-health-care-organizations-pursue-learning-and-exploration-diagnostic-excellence
    October 28, 2020 - Commentary Developing health care organizations that pursue learning and exploration of diagnostic excellence: an action plan. Citation Text: Singh H, Upadhyay DK, Torretti D. Developing Health Care Organizations That Pursue Learning and Exploration of Diagnostic Excellence: An Action Pl…

  18. IDEA4PS: the development of a research-oriented learning healthcare system. | PSNet

    psnet.ahrq.gov/issue/idea4ps-development-research-oriented-learning-healthcare-system
    April 24, 2018 - Commentary IDEA4PS: the development of a research-oriented learning healthcare system. Citation Text: Moffatt-Bruce SD, Huerta T, Gaughan A, et al. IDEA4PS: The Development of a Research-Oriented Learning Healthcare System. Am J Med Qual. 2018;33(4):420-425. doi:10.1177/1062860617751044.…

  19. Are personal health records (PHRs) facilitating patient safety? A scoping review. | PSNet

    psnet.ahrq.gov/issue/are-personal-health-records-phrs-facilitating-patient-safety-scoping-review
    February 09, 2022 - Review Are personal health records (PHRs) facilitating patient safety? A scoping review. Citation Text: Joseph AL, Monkman H, Kushniruk AW, et al. Are personal health records (PHRs) facilitating patient safety? A scoping review. Stud Health Technol Inform. 2022;2022:535-539. doi:10.3233/…

  20. Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. | PSNet

    psnet.ahrq.gov/issue/errors-administration-intravenous-medications-hospital-and-role-correct-procedures-and-nurse
    September 26, 2016 - Study Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. Citation Text: Westbrook JI, Rob MI, Woods A, et al. Errors in the administration of intravenous medications in hospital and the role of correct procedures a…
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