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psnet.ahrq.gov/issue/training-health-care-professionals-root-cause-analysis-cross-sectional-study-post-training
February 29, 2012 - Study
Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes.
Citation Text:
Bowie P, Skinner J, de Wet C. Training health care professionals in root cause analysis: a cross-sectional study of post-training…
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psnet.ahrq.gov/issue/effects-patient-environment-and-medication-related-factors-high-alert-medication-incidents
January 22, 2016 - Study
Effects of patient-, environment- and medication-related factors on high-alert medication incidents.
Citation Text:
Manias E, Williams A, Liew D, et al. Effects of patient-, environment- and medication-related factors on high-alert medication incidents. Int J Qual Health Care. 2014…
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psnet.ahrq.gov/issue/new-category-never-events-ending-harmful-hospital-policies
September 07, 2022 - Commentary
A new category of "never events"-ending harmful hospital policies.
Citation Text:
Chokshi DA, Beckman AL. A new category of "never events"-ending harmful hospital policies. JAMA Health Forum. 2022;3(10):e224703. doi:10.1001/jamahealthforum.2022.4703.
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psnet.ahrq.gov/issue/reducing-treatment-errors-through-point-care-glucometer-configuration
September 23, 2020 - Study
Reducing treatment errors through point-of-care glucometer configuration.
Citation Text:
Estock JL, Pham I-T, Curinga HK, et al. Reducing Treatment Errors Through Point-of-Care Glucometer Configuration. Jt Comm J Qual Patient Saf. 2018;44(11):683-694. doi:10.1016/j.jcjq.2018.03.014…
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psnet.ahrq.gov/issue/target-achieve-zero-preventable-trauma-deaths-through-quality-improvement
March 03, 2011 - Study
A target to achieve zero preventable trauma deaths through quality improvement.
Citation Text:
Hashmi ZG, Haut ER, Efron DT, et al. A Target to Achieve Zero Preventable Trauma Deaths Through Quality Improvement. JAMA Surg. 2018;153(7):686-689. doi:10.1001/jamasurg.2018.0159.
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psnet.ahrq.gov/issue/differential-perceptions-what-constitutes-medical-error-associated-electronic-medical-records
August 09, 2023 - Commentary
Differential perceptions of what constitutes a medical error associated with electronic medical records.
Citation Text:
Koppel R, Kuziemsky C, Elkin PL, et al. Differential perceptions of what constitutes a medical error associated with electronic medical records. Stud Health …
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psnet.ahrq.gov/issue/frequency-hiv-related-medication-errors-and-associated-risk-factors-hospitalized-patients
April 24, 2018 - Study
Frequency of HIV-related medication errors and associated risk factors in hospitalized patients.
Citation Text:
Pastakia SD, Corbett AH, Raasch RH, et al. Frequency of HIV-related medication errors and associated risk factors in hospitalized patients. Ann Pharmacother. 2008;42(4)…
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psnet.ahrq.gov/issue/starting-elective-cardiac-surgery-after-3-pm-does-not-impact-patient-morbidity-mortality-or
February 12, 2020 - Study
Starting elective cardiac surgery after 3 pm does not impact patient morbidity, mortality, or hospital costs.
Citation Text:
Axtell AL, Moonsamy P, Melnitchouk S, et al. Starting elective cardiac surgery after 3 pm does not impact patient morbidity, mortality, or hospital costs. J …
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psnet.ahrq.gov/issue/designing-critical-care-nurse-led-rapid-response-team-using-only-available-resources-6-years
December 21, 2014 - Study
Designing a critical care nurse–led rapid response team using only available resources: 6 years later.
Citation Text:
Mitchell A, Schatz M, Francis H. Designing a critical care nurse-led rapid response team using only available resources: 6 years later. Crit Care Nurse. 2014;34(3):…
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psnet.ahrq.gov/issue/simulator-based-crew-resource-management-training-interhospital-transfer-critically-ill
February 14, 2024 - Study
Simulator-based crew resource management training for interhospital transfer of critically ill patients by a mobile ICU.
Citation Text:
Droogh JM, Kruger HL, Ligtenberg JJM, et al. Simulator-Based Crew Resource Management Training for Interhospital Transfer of Critically Ill Pati…
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psnet.ahrq.gov/issue/medication-safety-neonatal-care-review-medication-errors-among-neonates
August 15, 2016 - Review
Medication safety in neonatal care: a review of medication errors among neonates.
Citation Text:
Krzyzaniak N, Bajorek B. Medication safety in neonatal care: a review of medication errors among neonates. Ther Adv Drug Saf. 2016;7(3):102-119. doi:10.1177/2042098616642231.
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psnet.ahrq.gov/issue/how-do-we-know-when-we-have-done-enough-ensuring-sufficient-patient-notification-efforts
August 18, 2021 - Commentary
How do we know when we have done enough? Ensuring sufficient patient notification efforts after a large-scale adverse event.
Citation Text:
Alfandre D, Foglia MB, Holodniy M, et al. How do we know when we have done enough? Ensuring sufficient patient notification efforts after…
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psnet.ahrq.gov/issue/developing-and-evaluating-large-language-model-generated-emergency-medicine-handoff-notes
March 12, 2025 - Study
Developing and evaluating large language model-generated emergency medicine handoff notes.
Citation Text:
Hartman V, Zhang X, Poddar R, et al. Developing and evaluating large language model-generated emergency medicine handoff notes. JAMA Netw Open. 2024;7(12):e2448723. doi:10.1001…
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psnet.ahrq.gov/issue/older-adult-misuse-over-counter-medications-effectiveness-novel-pharmacy-based-intervention
March 23, 2022 - Study
Older adult misuse of over-the-counter medications: effectiveness of a novel pharmacy-based intervention to improve patient safety.
Citation Text:
Gilson AM, Chladek JS, Stone JA, et al. Older adult misuse of over-the-counter medications: effectiveness of a novel pharmacy-based int…
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psnet.ahrq.gov/issue/diagnostic-discordance-uncertainty-and-treatment-ambiguity-community-acquired-pneumonia
June 07, 2023 - Study
Diagnostic discordance, uncertainty, and treatment ambiguity in community-acquired pneumonia: a national cohort study of 115 U.S. Veterans Affairs hospitals.
Citation Text:
Jones BE, Chapman AB, Ying J, et al. Diagnostic discordance, uncertainty, and treatment ambiguity in communit…
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psnet.ahrq.gov/issue/incidence-adverse-events-and-negligence-hospitalized-patients-results-harvard-medical
February 18, 2011 - Study
Classic
Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I.
Citation Text:
Brennan TA, Leape LL, Laird NM, et al. Incidence of Adverse Events and Negligence in Hospitalized Patients. N Eng…
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psnet.ahrq.gov/issue/toward-safer-health-care-system-critical-need-improve-measurement
November 03, 2015 - Commentary
Classic
Toward a safer health care system: the critical need to improve measurement.
Citation Text:
Jha AK, Pronovost P. Toward a Safer Health Care System: The Critical Need to Improve Measurement. JAMA. 2016;315(17):1831-2. doi:10.1001/jama.2016.3448…
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psnet.ahrq.gov/issue/anesthesia-related-closed-claims-free-standing-ambulatory-surgery-centers
March 29, 2023 - Study
Anesthesia-related closed claims in free-standing ambulatory surgery centers.
Citation Text:
Pimentel MPT, Chung S, Ross JM, et al. Anesthesia-related closed claims in free-standing ambulatory surgery centers. Anesth Analg. 2024;139(3):521-531. doi:10.1213/ane.0000000000006700.
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psnet.ahrq.gov/issue/communication-failure-analysis-prescribers-use-internal-free-text-field-electronic
May 20, 2019 - Study
Communication failure: analysis of prescribers' use of an internal free-text field on electronic prescriptions.
Citation Text:
Ai A, Wong A, Amato MG, et al. Communication failure: analysis of prescribers’ use of an internal free-text field on electronic prescriptions. J Am Med Inf…
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psnet.ahrq.gov/issue/association-display-patient-photographs-electronic-health-record-wrong-patient-order-entry
May 29, 2019 - Study
Association of display of patient photographs in the electronic health record with wrong-patient order entry errors.
Citation Text:
Salmasian H, Blanchfield BB, Joyce K, et al. Association of display of patient photographs in the electronic health record with wrong-patient order e…