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  1. Safety culture in the operating room: variability among perioperative healthcare workers. | PSNet

    psnet.ahrq.gov/issue/safety-culture-operating-room-variability-among-perioperative-healthcare-workers
    November 17, 2021 - Study Safety culture in the operating room: variability among perioperative healthcare workers. Citation Text: Pimentel MPT, Choi S, Fiumara K, et al. Safety culture in the operating room: variability among perioperative healthcare workers. J Patient Saf. 2021;17(6):412-416. doi:10.1097/…

  2. Safety management within the scope of teaching practical clinical skills: framing errors for cardiopulmonary resuscitation training - a multi-arm randomized controlled equivalence trial. | PSNet

    psnet.ahrq.gov/issue/safety-management-within-scope-teaching-practical-clinical-skills-framing-errors
    December 21, 2022 - Study Safety management within the scope of teaching practical clinical skills: framing errors for cardiopulmonary resuscitation training - a multi-arm randomized controlled equivalence trial. Citation Text: Schmidt M, Schauwinhold MT, Loeffler LAK, et al. Safety management within the sc…

  3. Implementation of electronic triggers to identify diagnostic errors in emergency departments. | PSNet

    psnet.ahrq.gov/issue/implementation-electronic-triggers-identify-diagnostic-errors-emergency-departments
    September 25, 2024 - Study Implementation of electronic triggers to identify diagnostic errors in emergency departments. Citation Text: Vaghani V, Gupta A, Mir U, et al. Implementation of electronic triggers to identify diagnostic errors in emergency departments. JAMA Intern Med. 2025;185(2):143-151. doi:10.…

  4. Promoting medication safety for older adults upon hospital discharge: guiding principles for a medication discharge plan. | PSNet

    psnet.ahrq.gov/issue/promoting-medication-safety-older-adults-upon-hospital-discharge-guiding-principles
    July 31, 2019 - Study Promoting medication safety for older adults upon hospital discharge: guiding principles for a medication discharge plan. Citation Text: Zhang FH, Lauzon J, Payette J, et al. Promoting medication safety for older adults upon hospital discharge: guiding principles for a medication d…

  5. Focused team engagements to enhance interprofessional collaboration and safety behaviors among novice nurses and medical residents. | PSNet

    psnet.ahrq.gov/issue/focused-team-engagements-enhance-interprofessional-collaboration-and-safety-behaviors-among
    March 02, 2022 - Study Focused team engagements to enhance interprofessional collaboration and safety behaviors among novice nurses and medical residents. Citation Text: Manuel R, Barber A, Kern J, et al. Focused team engagements to enhance interprofessional collaboration and safety behaviors among novic…

  6. Designing an intervention to improve medication safety for nursing home residents based on experiential knowledge related to patient safety culture at the nursing home front line: cocreative process study. | PSNet

    psnet.ahrq.gov/issue/designing-intervention-improve-medication-safety-nursing-home-residents-based-experiential
    February 14, 2024 - Commentary Designing an intervention to improve medication safety for nursing home residents based on experiential knowledge related to patient safety culture at the nursing home front line: cocreative process study. Citation Text: Juhl MH, Soerensen AL, Vardinghus-Nielsen H, et al. Desi…

  7. Evaluation and mitigation of the limitations of large language models in clinical decision-making. | PSNet

    psnet.ahrq.gov/issue/evaluation-and-mitigation-limitations-large-language-models-clinical-decision-making
    March 09, 2022 - Commentary Evaluation and mitigation of the limitations of large language models in clinical decision-making. Citation Text: Hager P, Jungmann F, Holland R, et al. Evaluation and mitigation of the limitations of large language models in clinical decision-making. Nat Med. 2024;30(9):2613-…

  8. Hospital rating organizations' quality and patient safety scores: analysis of result discrepancies. | PSNet

    psnet.ahrq.gov/issue/hospital-rating-organizations-quality-and-patient-safety-scores-analysis-result-discrepancies
    February 22, 2017 - Study Hospital rating organizations' quality and patient safety scores: analysis of result discrepancies. Citation Text: Badr S, Nahle T, Rahman S, et al. Hospital rating organizations' quality and patient safety scores: analysis of result discrepancies. J Gen Intern Med. 2025;40(3):525-…

  9. Evaluating the prevalence of four recommended practices for suicide prevention following hospital discharge. | PSNet

    psnet.ahrq.gov/issue/evaluating-prevalence-four-recommended-practices-suicide-prevention-following-hospital
    June 07, 2023 - Study Evaluating the prevalence of four recommended practices for suicide prevention following hospital discharge. Citation Text: Chitavi SO, Patrianakos J, Williams SC, et al. Evaluating the prevalence of four recommended practices for suicide prevention following hospital discharge. Jt…

  10. Misdiagnosis and failure to diagnose in emergency care: causes and empathy as a solution. | PSNet

    psnet.ahrq.gov/issue/misdiagnosis-and-failure-diagnose-emergency-care-causes-and-empathy-solution
    August 04, 2021 - Commentary Misdiagnosis and failure to diagnose in emergency care: causes and empathy as a solution. Citation Text: Pelaccia T, Messman AM, Kline JA. Misdiagnosis and failure to diagnose in emergency care: causes and empathy as a solution. Patient Edu Couns. 2020;103(8):1650-1656. doi:10…

  11. Emotionally evocative patients in the emergency department: a mixed methods investigation of providers' reported emotions and implications for patient safety | PSNet

    psnet.ahrq.gov/issue/emotionally-evocative-patients-emergency-department-mixed-methods-investigation-providers
    December 20, 2023 - Study Emotionally evocative patients in the emergency department: a mixed methods investigation of providers' reported emotions and implications for patient safety Citation Text: Isbell LM, Tager J, Beals K, et al. Emotionally evocative patients in the emergency department: a mixed metho…

  12. Factors contributing to an increase in duplicate medication order errors after CPOE implementation. | PSNet

    psnet.ahrq.gov/issue/factors-contributing-increase-duplicate-medication-order-errors-after-cpoe-implementation
    December 31, 2014 - Study Factors contributing to an increase in duplicate medication order errors after CPOE implementation. Citation Text: Wetterneck TB, Walker JM, Blosky MA, et al. Factors contributing to an increase in duplicate medication order errors after CPOE implementation. J Am Med Inform Assoc. …

  13. Intercepting wrong-patient orders in a computerized provider order entry system. | PSNet

    psnet.ahrq.gov/issue/intercepting-wrong-patient-orders-computerized-provider-order-entry-system
    May 29, 2019 - Study Intercepting wrong-patient orders in a computerized provider order entry system. Citation Text: Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider order entry system. Ann Emerg Med. 2015;65(6):679-686.e1. doi:10.1016/j.annemergmed…

  14. Transitioning between electronic health records: effects on ambulatory prescribing safety. | PSNet

    psnet.ahrq.gov/issue/transitioning-between-electronic-health-records-effects-ambulatory-prescribing-safety
    June 03, 2013 - Study Transitioning between electronic health records: effects on ambulatory prescribing safety. Citation Text: Abramson EL, Malhotra S, Fischer K, et al. Transitioning between electronic health records: effects on ambulatory prescribing safety. J Gen Intern Med. 2011;26(8):868-74. doi:1…

  15. Impact of a national QI programme on reducing electronic health record notifications to clinicians. | PSNet

    psnet.ahrq.gov/issue/impact-national-qi-programme-reducing-electronic-health-record-notifications-clinicians
    February 24, 2021 - Study Classic Impact of a national QI programme on reducing electronic health record notifications to clinicians. Citation Text: Shah T, Patel-Teague S, Kroupa L, et al. Impact of a national QI programme on reducing electronic health record notifications to clin…

  16. Medication-related emergency department visits in pediatrics: a prospective observational study. | PSNet

    psnet.ahrq.gov/issue/medication-related-emergency-department-visits-pediatrics-prospective-observational-study
    October 16, 2013 - Study Medication-related emergency department visits in pediatrics: a prospective observational study. Citation Text: Zed PJ, Black KJL, Fitzpatrick EA, et al. Medication-related emergency department visits in pediatrics: a prospective observational study. Pediatrics. 2015;135(3):435-43.…

  17. Burnout in the NICU setting and its relation to safety culture. | PSNet

    psnet.ahrq.gov/issue/burnout-nicu-setting-and-its-relation-safety-culture
    February 13, 2019 - Study Burnout in the NICU setting and its relation to safety culture. Citation Text: Profit J, Sharek PJ, Amspoker AB, et al. Burnout in the NICU setting and its relation to safety culture. BMJ Qual Saf. 2014;23(10):806-813. doi:10.1136/bmjqs-2014-002831. Copy Citation Format: …

  18. WHO research agenda on the role of the institutional safety climate for hand hygiene improvement: a Delphi consensus-building study. | PSNet

    psnet.ahrq.gov/issue/who-research-agenda-role-institutional-safety-climate-hand-hygiene-improvement-delphi
    February 01, 2011 - Study WHO research agenda on the role of the institutional safety climate for hand hygiene improvement: a Delphi consensus-building study. Citation Text: Tartari E, Storr J, Bellare N, et al. WHO research agenda on the role of the institutional safety climate for hand hygiene improvement…

  19. ICD-10 codes used to identify adverse drug events in administrative data: a systematic review. | PSNet

    psnet.ahrq.gov/issue/icd-10-codes-used-identify-adverse-drug-events-administrative-data-systematic-review
    September 14, 2016 - Review ICD-10 codes used to identify adverse drug events in administrative data: a systematic review. Citation Text: Hohl CM, Karpov A, Reddekopp L, et al. ICD-10 codes used to identify adverse drug events in administrative data: a systematic review. J Am Med Inform Assoc. 2014;21(3):547…

  20. Exploring the "Black Box" of recommendation generation in local health care incident investigations: a scoping review. | PSNet

    psnet.ahrq.gov/issue/exploring-black-box-recommendation-generation-local-health-care-incident-investigations
    November 16, 2016 - Review Exploring the "Black Box" of recommendation generation in local health care incident investigations: a scoping review. Citation Text: Lea W, Lawton R, Vincent CA, et al. Exploring the "Black Box" of recommendation generation in local health care incident investigations: a scoping …
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