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  1. Team safety and innovation by learning from errors in long-term care settings. | PSNet

    psnet.ahrq.gov/issue/team-safety-and-innovation-learning-errors-long-term-care-settings
    March 05, 2010 - Study Team safety and innovation by learning from errors in long-term care settings. Citation Text: Buljac-Samardzic M, van Woerkom M, Paauwe J. Team safety and innovation by learning from errors in long-term care settings. Health Care Manage Rev. 2012;37(3):280-91. doi:10.1097/HMR.0b0…

  2. The impact of hindsight bias on the diagnosis of perioperative events by anesthesia providers: a multicenter randomized crossover study. | PSNet

    psnet.ahrq.gov/issue/impact-hindsight-bias-diagnosis-perioperative-events-anesthesia-providers-multicenter
    December 16, 2020 - Study The impact of hindsight bias on the diagnosis of perioperative events by anesthesia providers: a multicenter randomized crossover study. Citation Text: Millan PD, Kleiman AM, Friedman JF, et al. The impact of hindsight bias on the diagnosis of perioperative events by anesthesia pro…

  3. Personal health records: a randomized trial of effects on elder medication safety. | PSNet

    psnet.ahrq.gov/issue/personal-health-records-randomized-trial-effects-elder-medication-safety
    November 16, 2022 - Study Personal health records: a randomized trial of effects on elder medication safety. Citation Text: Chrischilles EA, Hourcade JP, Doucette W, et al. Personal health records: a randomized trial of effects on elder medication safety. J Am Med Inform Assoc. 2014;21(4):679-86. doi:10.113…

  4. Implementation of safeguards to improve patient safety in chemotherapy. | PSNet

    psnet.ahrq.gov/issue/implementation-safeguards-improve-patient-safety-chemotherapy
    September 19, 2012 - Study Implementation of safeguards to improve patient safety in chemotherapy. Citation Text: Huertas-Fernández MJ, Martínez-Bautista Mª J, Rodríguez-Mateos ME, et al. Implementation of safeguards to improve patient safety in chemotherapy. Clin Transl Oncol. 2017;19(9):1099-1106. doi:10.1…

  5. Accident analysis of large-scale technological disasters applied to an anaesthetic complication. | PSNet

    psnet.ahrq.gov/issue/accident-analysis-large-scale-technological-disasters-applied-anaesthetic-complication
    November 16, 2022 - Study Classic Accident analysis of large-scale technological disasters applied to an anaesthetic complication. Citation Text: Eagle CJ, Davies JM, Reason J. Accident analysis of large-scale technological disasters applied to an anaesthetic complication. Can J An…

  6. Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003. | PSNet

    psnet.ahrq.gov/issue/probabilistic-risk-assessment-accidental-abo-incompatible-thoracic-organ-transplantation-and
    June 24, 2020 - Study Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003. Citation Text: Cook RI, Wreathall J, Smith A, et al. Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 200…

  7. Initiatives to identify and mitigate medication errors in England. | PSNet

    psnet.ahrq.gov/issue/initiatives-identify-and-mitigate-medication-errors-england
    July 22, 2020 - Commentary Initiatives to identify and mitigate medication errors in England. Citation Text: Cousins D, Gerrett D, Richards N, et al. Initiatives to identify and mitigate medication errors in England. Drug Saf. 2015;38(4):349-357. doi:10.1007/s40264-015-0270-3. Copy Citation Format…

  8. Randomized trial to improve prescribing safety in ambulatory elderly patients. | PSNet

    psnet.ahrq.gov/issue/randomized-trial-improve-prescribing-safety-ambulatory-elderly-patients
    March 10, 2011 - Study Randomized trial to improve prescribing safety in ambulatory elderly patients. Citation Text: Raebel MA, Charles J, Dugan J, et al. Randomized trial to improve prescribing safety in ambulatory elderly patients. J Am Geriatr Soc. 2007;55(7):977-85. Copy Citation Format: …

  9. Listen to the whispers before they become screams: addressing Black maternal morbidity and mortality in the United States. | PSNet

    psnet.ahrq.gov/issue/listen-whispers-they-become-screams-addressing-black-maternal-morbidity-and-mortality-united
    December 05, 2012 - Commentary Listen to the whispers before they become screams: addressing Black maternal morbidity and mortality in the United States. Citation Text: Njoku A, Evans M, Nimo-Sefah L, et al. Listen to the whispers before they become screams: addressing Black maternal morbidity and mortality…

  10. Using potentially preventable severe maternal morbidity to monitor hospital performance. | PSNet

    psnet.ahrq.gov/issue/using-potentially-preventable-severe-maternal-morbidity-monitor-hospital-performance
    February 02, 2022 - Study Using potentially preventable severe maternal morbidity to monitor hospital performance. Citation Text: Fridman M, Korst LM, Reynen DJ, et al. Using potentially preventable severe maternal morbidity to monitor hospital performance. Jt Comm J Qual Patient Saf. 2023;49(3):129-137. do…

  11. The racial disparities in maternal mortality and impact of structural racism and implicit racial bias on pregnant Black women: a review of the literature. | PSNet

    psnet.ahrq.gov/issue/racial-disparities-maternal-mortality-and-impact-structural-racism-and-implicit-racial-bias
    July 13, 2009 - Review The racial disparities in maternal mortality and impact of structural racism and implicit racial bias on pregnant Black women: a review of the literature. Citation Text: Montalmant KE, Ettinger AK. The racial disparities in maternal mortality and impact of structural racism and im…

  12. Black women's maternal health: insights from community based participatory research in Newark, New Jersey. | PSNet

    psnet.ahrq.gov/issue/black-womens-maternal-health-insights-community-based-participatory-research-newark-new
    June 21, 2023 - Study Black women's maternal health: insights from community based participatory research in Newark, New Jersey. Citation Text: Kantor LM, Cruz N, Adams C, et al. Black women's maternal health: insights from community based participatory research in Newark, New Jersey. Behav Med. 2024;50…

  13. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. | PSNet

    psnet.ahrq.gov/issue/centers-disease-control-and-prevention-guideline-prevention-surgical-site-infection-2017
    June 27, 2018 - Review Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. Citation Text: Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JA…

  14. Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. | PSNet

    psnet.ahrq.gov/issue/reducing-rate-catheter-associated-bloodstream-infections-surgical-intensive-care-unit-using
    November 16, 2022 - Study Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. Citation Text: Sacks GD, Diggs BS, Hadjizacharia P, et al. Reducing the rate of catheter-associated bloodstream infe…

  15. Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit. | PSNet

    psnet.ahrq.gov/issue/impact-drug-shortage-medication-errors-and-clinical-outcomes-pediatric-intensive-care-unit
    November 16, 2022 - Study Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit. Citation Text: Hughes KM, Goswami ES, Morris JL. Impact of a Drug Shortage on Medication Errors and Clinical Outcomes in the Pediatric Intensive Care Unit. J Pediatr Pharmacol…

  16. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. | PSNet

    psnet.ahrq.gov/issue/causes-medication-administration-errors-hospitals-systematic-review-quantitative-and
    April 01, 2015 - Review Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Citation Text: Keers RN, Williams SD, Cooke J, et al. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitativ…

  17. Liability claims and costs before and after implementation of a medical error disclosure program. | PSNet

    psnet.ahrq.gov/issue/liability-claims-and-costs-and-after-implementation-medical-error-disclosure-program
    April 24, 2018 - Study Classic Liability claims and costs before and after implementation of a medical error disclosure program. Citation Text: Kachalia A, Kaufman SR, Boothman RC, et al. Liability claims and costs before and after implementation of a medical error disclosure …

  18. AHRQ Nursing Home Survey on Patient Safety Culture: 2016 User Comparative Database Report. | PSNet

    psnet.ahrq.gov/issue/ahrq-nursing-home-survey-patient-safety-culture-2016-user-comparative-database-report
    June 08, 2016 - Government Resource AHRQ Nursing Home Survey on Patient Safety Culture: 2016 User Comparative Database Report. Citation Text: AHRQ Nursing Home Survey on Patient Safety Culture: 2016 User Comparative Database Report. Famolaro T, Yount ND, Greene, K, Hare R, Thorton S, Sorra J. Rockville,…

  19. Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. | PSNet

    psnet.ahrq.gov/issue/putting-action-rca2-analysis-intervention-strength-after-adverse-events
    April 17, 2024 - Study Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. Citation Text: Zerillo JA, Tardiff SA, Flood D, et al. Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. Jt Comm J Qual Patient Saf. 2024;50(7):492-49…

  20. Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017. | PSNet

    psnet.ahrq.gov/issue/prevalence-potentially-inappropriate-medication-prescribing-us-nursing-homes-2013-2017
    March 27, 2024 - Study Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017. Citation Text: Riester MR, Goyal P, Steinman MA, et al. Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017. J Gen Intern Med. 2023;38(6):1563-15…
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