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  1. A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognised patient risk. | PSNet

    psnet.ahrq.gov/issue/qualitative-study-examining-influences-situation-awareness-and-identification-mitigation-and
    July 16, 2014 - Study A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognised patient risk. Citation Text: Brady PW, Goldenhar LM. A qualitative study examining the influences on situation awareness and the identification, miti…

  2. Aseptic Catheter Insertion Practices in the ED: A Focus on Engagement | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cauti-tools/archived-webinars/aseptic-catheter-insertion-practices-ed-slides.html
    December 01, 2017 - Aseptic Catheter Insertion Practices in the ED: A Focus on Engagement Slide Presentation Slide 1 Aseptic Catheter Insertion Practices in the ED: A Focus on Engagement Milisa Manojlovich PhD, RN, CCRN Associate Professor University of Michigan, School of Nursing Slide 2 Learning Objectives Di…

  3. Public comment period extended for strategies to improve patient safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine. | PSNet

    psnet.ahrq.gov/issue/public-comment-period-extended-strategies-improve-patient-safety-draft-report-congress-public
    June 16, 2021 - Press Release/Announcement Public comment period extended for strategies to improve patient safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine. Citation Text: Public comment period extended for strategies to improve patient safety: Draft Re…

  4. What did the doctor say? Health literacy and recall of medical instructions. | PSNet

    psnet.ahrq.gov/issue/what-did-doctor-say-health-literacy-and-recall-medical-instructions
    December 21, 2014 - Study What did the doctor say? Health literacy and recall of medical instructions. Citation Text: McCarthy D, Waite KR, Curtis LM, et al. What did the doctor say? Health literacy and recall of medical instructions. Med Care. 2012;50(4):277-82. doi:10.1097/MLR.0b013e318241e8e1. Copy C…

  5. One hospital's initiatives to encourage safe opioid use. | PSNet

    psnet.ahrq.gov/issue/one-hospitals-initiatives-encourage-safe-opioid-use
    October 19, 2022 - Commentary One hospital's initiatives to encourage safe opioid use. Citation Text: Surprise JK, Simpson MH. One Hospital's Initiatives to Encourage Safe Opioid Use. J Infus Nurs. 2015;38(4):278-83. doi:10.1097/NAN.0000000000000110. Copy Citation Format: DOI Google Scholar P…

  6. Bar code technology and medication administration error. | PSNet

    psnet.ahrq.gov/issue/bar-code-technology-and-medication-administration-error
    June 07, 2023 - Review Bar code technology and medication administration error. Citation Text: Young J, Slebodnik M, Sands L. Bar Code Technology and Medication Administration Error. J Patient Saf. 2010;6(2):115-120. doi:10.1097/pts.0b013e3181de35f7. Copy Citation Format: DOI Google Scho…

  7. Enhanced morbidity and mortality meeting and patient safety education for specialty trainees. | PSNet

    psnet.ahrq.gov/issue/enhanced-morbidity-and-mortality-meeting-and-patient-safety-education-specialty-trainees
    December 31, 2012 - Study Enhanced morbidity and mortality meeting and patient safety education for specialty trainees. Citation Text: Singh HP, Durani P, Dias JJ. Enhanced Morbidity and Mortality Meeting and Patient Safety Education for Specialty Trainees. J Patient Saf. 2019;15(1):37-48. doi:10.1097/PTS.0…

  8. System weaknesses as contributing causes of accidents in health care. | PSNet

    psnet.ahrq.gov/issue/system-weaknesses-contributing-causes-accidents-health-care
    August 31, 2022 - Study System weaknesses as contributing causes of accidents in health care. Citation Text: Ternov S, Akselsson R. System weaknesses as contributing causes of accidents in health care. Int J Qual Health Care. 2005;17(1):5-13. Copy Citation Format: Google Scholar PubMed Bib…

  9. Eradicating medical student mistreatment: a longitudinal study of one institution's efforts. | PSNet

    psnet.ahrq.gov/issue/eradicating-medical-student-mistreatment-longitudinal-study-one-institutions-efforts
    August 28, 2019 - Study Eradicating medical student mistreatment: a longitudinal study of one institution's efforts. Citation Text: Fried JM, Vermillion M, Parker NH, et al. Eradicating medical student mistreatment: a longitudinal study of one institution's efforts. Acad Med. 2012;87(9):1191-1198. Copy …

  10. Characteristics of medical professional liability claims in patients with cardiovascular diseases. | PSNet

    psnet.ahrq.gov/issue/characteristics-medical-professional-liability-claims-patients-cardiovascular-diseases
    August 02, 2015 - Study Characteristics of medical professional liability claims in patients with cardiovascular diseases. Citation Text: Oetgen WJ, Parikh D, Cacchione JG, et al. Characteristics of medical professional liability claims in patients with cardiovascular diseases. Am J Cardiol. 2010;105(5):…

  11. Evidence and efficacy: time to think beyond the traditional randomised controlled trial in patient safety studies. | PSNet

    psnet.ahrq.gov/issue/evidence-and-efficacy-time-think-beyond-traditional-randomised-controlled-trial-patient
    January 24, 2024 - Commentary Evidence and efficacy: time to think beyond the traditional randomised controlled trial in patient safety studies. Citation Text: Webster CS. Evidence and efficacy: time to think beyond the traditional randomised controlled trial in patient safety studies. Br J Anaesth. 2019;1…

  12. Investigating the causes of adverse events. | PSNet

    psnet.ahrq.gov/issue/investigating-causes-adverse-events
    October 03, 2017 - Commentary Investigating the causes of adverse events. Citation Text: Sanchez JA, Lobdell KW, Moffatt-Bruce SD, et al. Investigating the Causes of Adverse Events. Ann Thorac Surg. 2017;103(6):1693-1699. doi:10.1016/j.athoracsur.2017.04.001. Copy Citation Format: DOI Google …

  13. View the world through a different lens: shadowing another provider. | PSNet

    psnet.ahrq.gov/issue/view-world-through-different-lens-shadowing-another-provider
    January 22, 2017 - Commentary View the world through a different lens: shadowing another provider. Citation Text: Thompson DA, Holzmueller CG, Lubomski LH, et al. View the world through a different lens: shadowing another provider. Jt Comm J Qual Patient Saf. 2008;34(10):614-8, 561. Copy Citation For…

  14. Approaching the evidence basis for aviation-derived teamwork training in medicine. | PSNet

    psnet.ahrq.gov/issue/approaching-evidence-basis-aviation-derived-teamwork-training-medicine
    August 09, 2023 - Review Approaching the evidence basis for aviation-derived teamwork training in medicine. Citation Text: Zeltser M, Nash DB. Approaching the evidence basis for aviation-derived teamwork training in medicine. Am J Med Qual. 2010;25(1):13-23. doi:10.1177/1062860609345664. Copy Citation…

  15. A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety. | PSNet

    psnet.ahrq.gov/issue/systematic-review-human-factors-and-ergonomics-hfe-based-healthcare-system-redesign-quality
    February 13, 2014 - Review A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety. Citation Text: Xie A, Carayon P. A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and pa…

  16. Survey results: smart pump data analytics pump metrics that should be monitored to improve safety. | PSNet

    psnet.ahrq.gov/issue/survey-results-smart-pump-data-analytics-pump-metrics-should-be-monitored-improve-safety
    August 08, 2018 - Newspaper/Magazine Article Survey results: smart pump data analytics pump metrics that should be monitored to improve safety. Citation Text: Survey results: smart pump data analytics pump metrics that should be monitored to improve safety. ISMP Medication Safety Alert! Acute care edition…

  17. Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cauti-tools/impl-guide/index.html
    October 01, 2015 - Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide Next Page Table of Contents Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide Overview Frameworks for Change and Improvement Technical…

  18. 5 Tk2 P3T6-Sample Vignettes Phase 3 Final (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T6-Sample_Vignettes_Phase_3_final.doc
    June 02, 2025 - Comprehensive Antibiogram Toolkit: Phase 3 Sample Vignettes The following series of vignettes are similar to cases that a prescribing clinician may be presented with in a nursing home. Work through the vignettes and discussion questions—first without referring to the antibiogram and then by referring to the antibiogra…

  19. The role of chief executive officers in a quality improvement: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/role-chief-executive-officers-quality-improvement-qualitative-study
    September 17, 2014 - Study The role of chief executive officers in a quality improvement: a qualitative study. Citation Text: Parand A, Dopson S, Vincent CA. The role of chief executive officers in a quality improvement : a qualitative study. BMJ Open. 2013;3(1). doi:10.1136/bmjopen-2012-001731. Copy Citat…

  20. Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors' and nurses' views. | PSNet

    psnet.ahrq.gov/issue/rules-and-guidelines-clinical-practice-qualitative-study-operating-theatres-doctors-and
    January 06, 2018 - Study Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors' and nurses' views. Citation Text: McDonald R. Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors' and nurses' views. Quality and Safety in…
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