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  1. What are we missing? The quality of intraoperative handover before and after introduction of a checklist. | PSNet

    psnet.ahrq.gov/issue/what-are-we-missing-quality-intraoperative-handover-and-after-introduction-checklist
    January 12, 2022 - Study What are we missing? The quality of intraoperative handover before and after introduction of a checklist. Citation Text: Lane S, Gross M, Arzola C, et al. What are we missing? The quality of intraoperative handover before and after introduction of a checklist. Can J Anaesth. 2022;6…

  2. Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s largest event reporting database. | PSNet

    psnet.ahrq.gov/issue/patient-safety-trends-2021-analysis-288882-serious-events-and-incidents-nations-largest-event
    May 19, 2021 - Study Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s largest event reporting database. Citation Text: Kepner S, Jones RM. Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s largest eve…

  3. Eliminating explicit and implicit biases in health care: evidence and research needs. | PSNet

    psnet.ahrq.gov/issue/eliminating-explicit-and-implicit-biases-health-care-evidence-and-research-needs
    May 11, 2016 - Review Eliminating explicit and implicit biases in health care: evidence and research needs. Citation Text: Vela MB, Erondu AI, Smith NA, et al. Eliminating explicit and implicit biases in health care: evidence and research needs. Annu Rev Public Health. 2022;43(1):477-501. doi:10.1146/…

  4. One-stop diagnostic breast clinics: how often are breast cancers missed? | PSNet

    psnet.ahrq.gov/issue/one-stop-diagnostic-breast-clinics-how-often-are-breast-cancers-missed
    August 04, 2021 - Study One-stop diagnostic breast clinics: how often are breast cancers missed? Citation Text: Britton P, Duffy SW, Sinnatamby R, et al. One-stop diagnostic breast clinics: how often are breast cancers missed? Br J Cancer. 2009;100(12). doi:10.1038/sj.bjc.6605082. Copy Citation Fo…

  5. Analyzing and mitigating the risks of patient harm during operating room to intensive care unit patient handoffs. | PSNet

    psnet.ahrq.gov/issue/analyzing-and-mitigating-risks-patient-harm-during-operating-room-intensive-care-unit-patient
    October 05, 2022 - Commentary Analyzing and mitigating the risks of patient harm during operating room to intensive care unit patient handoffs. Citation Text: Martins NRS, Martinez EZ, Simões CM, et al. Analyzing and mitigating the risks of patient harm during operating room to intensive care unit patient …

  6. U.S. Preventive Services Task Force Issues Final Recommendation on Screening for Syphilis Infection (pdf file)

    www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/syphilis-nonpregnant-adults-adolescents-screening-final-rec-bulletin.pdf
    September 27, 2022 - U.S. Preventive Services Task Force Issues Final Recommendation on Screening for Syphilis Infection http://www.uspreventiveservicestaskforce.org 1 U.S. Preventive Services Task Force Issues Final Recommendation on Screening for Syphilis Infection Task Force recommends screening people at increased risk fo…

  7. Shining a Light: Safer Health Care Through Transparency. | PSNet

    psnet.ahrq.gov/issue/shining-light-safer-health-care-through-transparency
    November 23, 2016 - Book/Report Shining a Light: Safer Health Care Through Transparency. Citation Text: Shining a Light: Safer Health Care Through Transparency. Boston, MA: National Patient Safety Foundation Lucian Leape Institute; January 2015. Copy Citation Save Save to your librar…

  8. More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA. | PSNet

    psnet.ahrq.gov/issue/more-algorithms-analysis-safety-events-involving-ml-enabled-medical-devices-reported-fda
    May 01, 2019 - Study More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA. Citation Text: Lyell D, Wang Y, Coiera E, et al. More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA. J Am Med Inform…

  9. An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting. | PSNet

    psnet.ahrq.gov/issue/analysis-structure-and-content-dashboards-used-monitor-patient-safety-inpatient-setting
    March 09, 2022 - Study An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting. Citation Text: Kuznetsova M, Frits ML, Dulgarian S, et al. An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting.…

  10. The potential for leveraging machine learning to filter medication alerts. | PSNet

    psnet.ahrq.gov/issue/potential-leveraging-machine-learning-filter-medication-alerts
    July 22, 2020 - Study The potential for leveraging machine learning to filter medication alerts. Citation Text: Liu S, Kawamoto K, Del Fiol G, et al. The potential for leveraging machine learning to filter medication alerts. J Am Med Inform Assoc. 2022;29(5):891-899. doi:10.1093/jamia/ocab292. Copy Ci…

  11. Defining avoidable healthcare-associated harm in prisons: a mixed-method development study. | PSNet

    psnet.ahrq.gov/issue/defining-avoidable-healthcare-associated-harm-prisons-mixed-method-development-study
    August 04, 2021 - Study Defining avoidable healthcare-associated harm in prisons: a mixed-method development study. Citation Text: Keers RN, Wainwright V, McFadzean J, et al. Defining avoidable healthcare-associated harm in prisons: a mixed-method development study. PLOS One. 2023;18(3):e0282021. doi:10.1…

  12. Inter-hospital transfer is an independent risk factor for hospital-associated infection. | PSNet

    psnet.ahrq.gov/issue/inter-hospital-transfer-independent-risk-factor-hospital-associated-infection
    August 26, 2011 - Study Inter-hospital transfer is an independent risk factor for hospital-associated infection. Citation Text: Gardner C, Rubinfeld IS, Gupta AH, et al. Inter-hospital transfer is an independent risk factor for hospital-associated infection. Surg Infect (Larchmt). 2024;25(2):125-132. doi:…

  13. Inappropriate prescribing of opioids for patients undergoing surgery. | PSNet

    psnet.ahrq.gov/issue/inappropriate-prescribing-opioids-patients-undergoing-surgery
    June 30, 2021 - Study Inappropriate prescribing of opioids for patients undergoing surgery. Citation Text: Varady NH, Worsham CM, Chen AF, et al. Inappropriate prescribing of opioids for patients undergoing surgery. Proc Natl Acad Sci USA. 2022;119(49):e2210226119. doi:10.1073/pnas.2210226119. Copy Ci…

  14. Association of safety culture with surgical site infection outcomes. | PSNet

    psnet.ahrq.gov/issue/association-safety-culture-surgical-site-infection-outcomes
    October 23, 2024 - Study Classic Association of safety culture with surgical site infection outcomes. Citation Text: Fan CJ, Pawlik TM, Daniels T, et al. Association of safety culture with surgical site infection outcomes. J Am Coll Surg. 2016;222(2):122-128. doi:10.1016/j.jamcoll…

  15. Safe clinical practice for patients hospitalised in mental health wards during a suicidal crisis: qualitative study of patient experiences. | PSNet

    psnet.ahrq.gov/issue/safe-clinical-practice-patients-hospitalised-mental-health-wards-during-suicidal-crisis
    August 17, 2022 - Study Safe clinical practice for patients hospitalised in mental health wards during a suicidal crisis: qualitative study of patient experiences. Citation Text: Berg SH, Rørtveit K, Walby FA, et al. Safe clinical practice for patients hospitalised in mental health wards during a suicidal…

  16. Adverse events involving telehealth in the Veterans Health Administration. | PSNet

    psnet.ahrq.gov/issue/adverse-events-involving-telehealth-veterans-health-administration
    October 26, 2022 - Review Adverse events involving telehealth in the Veterans Health Administration. Citation Text: Mills PD, Tomolo A, Yackel EE. Adverse events involving telehealth in the Veterans Health Administration. Jt Comm J Qual Patient Saf. 2024;Epub Dec 20. doi:10.1016/j.jcjq.2024.12.002. Copy …

  17. A Patient’s Guide to Warm Handoffs (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-patient-guide.pdf
    June 02, 2025 - A Patient’s Guide to Warm Handoffs Why is it important? A warm handoff: ■ Lets you hear what your providers are saying about your health and your plan of care. ■ Encourages you to speak up, ask questions, and join the conversation about your health. ■ Gives you a chance to correct or clarify any information…

  18. Pediatric obesity and safety in inpatient settings: a systematic literature review. | PSNet

    psnet.ahrq.gov/issue/pediatric-obesity-and-safety-inpatient-settings-systematic-literature-review
    November 12, 2014 - Review Pediatric obesity and safety in inpatient settings: a systematic literature review. Citation Text: Halvorson EE, Irby MB, Skelton JA. Pediatric obesity and safety in inpatient settings: a systematic literature review. Clin Pediatr (Phila). 2014;53(10):975-87. doi:10.1177/000992281…

  19. Warm Handoffs: A Guide for Clinicians (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-guide-for-clinicians.pdf
    June 02, 2025 - Warm Handoffs: A Guide for Clinicians Why is it important? Communication breakdowns can result in medical errors. Warm handoffs can help address communication issues and: ■ Engage patients and families and encourage them to ask questions. ■ Allow patients to clarify or correct the information exchanged. ■…

  20. Warm Handoffs: A Guide for Staff (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-guide-for-staff.pdf
    June 02, 2025 - Warm Handoffs: A Guide for Staff Why is it important? Warm handoffs can: ■ Engage patients and families as team members. ■ Allow patients to clarify or correct the information exchanged. ■ Build relationships. ■ Provide a safety check. Guide to Patient and Family Engagement in Primary Care How do I conduc…
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