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  1. Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research. | PSNet

    psnet.ahrq.gov/issue/overdiagnosis-and-overtreatment-quality-problem-insights-healthcare-improvement-research
    May 25, 2022 - Commentary Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research. Citation Text: Armstrong N. Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research. BMJ Qual Saf. 2018;27(7):571-575. doi:10.1136/b…

  2. Notice of Intent to Publish Funding Opportunity Announcements to Understand and Improve Diagnostic Safety in Ambulatory Care. | PSNet

    psnet.ahrq.gov/issue/notice-intent-publish-funding-opportunity-announcements-understand-and-improve-diagnostic
    August 15, 2018 - Press Release/Announcement Notice of Intent to Publish Funding Opportunity Announcements to Understand and Improve Diagnostic Safety in Ambulatory Care. Citation Text: Notice of Intent to Publish Funding Opportunity Announcements to Understand and Improve Diagnostic Safety in Ambulatory …

  3. Health literacy and quality: focus on chronic illness care and patient safety. | PSNet

    psnet.ahrq.gov/issue/health-literacy-and-quality-focus-chronic-illness-care-and-patient-safety
    September 26, 2012 - Commentary Health literacy and quality: focus on chronic illness care and patient safety. Citation Text: Rothman RL, Yin S, Mulvaney S, et al. Health literacy and quality: focus on chronic illness care and patient safety. Pediatrics. 2009;124 Suppl 3:S315-S326. doi:10.1542/peds.2009-11…

  4. Promoting patient safety: results of a TeamSTEPPS initiative. | PSNet

    psnet.ahrq.gov/issue/promoting-patient-safety-results-teamstepps-initiative
    October 17, 2012 - Commentary Promoting patient safety: results of a TeamSTEPPS initiative. Citation Text: Gaston T, Short N, Ralyea C, et al. Promoting patient safety: results of a TeamSTEPPS initiative. J Nurs Adm. 2016;46(4):201-207. doi:10.1097/nna.0000000000000333. Copy Citation Format: …

  5. Factors associated with reported preventable adverse drug events: a retrospective, case-control study. | PSNet

    psnet.ahrq.gov/issue/factors-associated-reported-preventable-adverse-drug-events-retrospective-case-control-study
    November 16, 2022 - Study Factors associated with reported preventable adverse drug events: a retrospective, case-control study. Citation Text: Beckett RD, Sheehan AH, Reddan JG. Factors associated with reported preventable adverse drug events: a retrospective, case-control study. Ann Pharmacother. 2012;46…

  6. Safety huddles in the PACU: when a patient self-medicates. | PSNet

    psnet.ahrq.gov/issue/safety-huddles-pacu-when-patient-self-medicates
    December 14, 2016 - Commentary Safety huddles in the PACU: when a patient self-medicates. Citation Text: Setaro J, Connolly M. Safety huddles in the PACU: when a patient self-medicates. J Perianesth Nurs. 2011;26(2):96-102. doi:10.1016/j.jopan.2011.01.010. Copy Citation Format: DOI Google Sc…

  7. Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit. | PSNet

    psnet.ahrq.gov/issue/improving-teamwork-impact-structured-interdisciplinary-rounds-medical-teaching-unit
    December 21, 2014 - Study Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit. Citation Text: O'Leary KJ, Wayne DB, Haviley C, et al. Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit. J Gen Intern Med. 2010;25(8):826-32. do…

  8. Medical errors: disclosure styles, interpersonal forgiveness, and outcomes. | PSNet

    psnet.ahrq.gov/issue/medical-errors-disclosure-styles-interpersonal-forgiveness-and-outcomes
    June 14, 2017 - Study Medical errors: disclosure styles, interpersonal forgiveness, and outcomes. Citation Text: Hannawa AF, Shigemoto Y, Little TD. Medical errors: Disclosure styles, interpersonal forgiveness, and outcomes. Social Sci Med. 2016;156:29-38. doi:10.1016/j.socscimed.2016.03.026. Copy Cit…

  9. Defining technical errors in laparoscopic surgery: a systematic review. | PSNet

    psnet.ahrq.gov/issue/defining-technical-errors-laparoscopic-surgery-systematic-review
    September 11, 2013 - Review Defining technical errors in laparoscopic surgery: a systematic review. Citation Text: Bonrath EM, Dedy NJ, Zevin B, et al. Defining technical errors in laparoscopic surgery: a systematic review. Surg Endosc. 2013;27(8):2678-91. doi:10.1007/s00464-013-2827-5. Copy Citation …

  10. The role of talking (and keeping silent) in physician coping with medical error: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/role-talking-and-keeping-silent-physician-coping-medical-error-qualitative-study
    February 16, 2011 - Study The role of talking (and keeping silent) in physician coping with medical error: a qualitative study. Citation Text: May NB, Plews-Ogan M. The role of talking (and keeping silent) in physician coping with medical error: a qualitative study. Patient Educ Couns. 2012;88(3):449-54. …

  11. Human factors in surgery: from Three Mile Island to the operating room. | PSNet

    psnet.ahrq.gov/issue/human-factors-surgery-three-mile-island-operating-room
    July 12, 2019 - Review Human factors in surgery: from Three Mile Island to the operating room. Citation Text: D'Addessi A, Bongiovanni L, Volpe A, et al. Human factors in surgery: from Three Mile Island to the operating room. Urol Int. 2009;83(3):249-57. doi:10.1159/000241662. Copy Citation Form…

  12. Prescription of teratogenic medications in United States ambulatory practices. | PSNet

    psnet.ahrq.gov/issue/prescription-teratogenic-medications-united-states-ambulatory-practices
    March 23, 2012 - Study Prescription of teratogenic medications in United States ambulatory practices. Citation Text: Schwarz EB, Maselli J, Norton M, et al. Prescription of teratogenic medications in United States ambulatory practices. Am J Med. 2005;118(11):1240-9. Copy Citation Format: …

  13. Using smart pumps to understand and evaluate clinician practice patterns to ensure patient safety. | PSNet

    psnet.ahrq.gov/issue/using-smart-pumps-understand-and-evaluate-clinician-practice-patterns-ensure-patient-safety
    September 01, 2016 - Study Using smart pumps to understand and evaluate clinician practice patterns to ensure patient safety. Citation Text: Mansfield J, Jarrett S. Using smart pumps to understand and evaluate clinician practice patterns to ensure patient safety. Hosp Pharm. 2013;48(11):942-950. doi:10.1310…

  14. Hiding in plain sight—resurrecting the power of inspecting the patient. | PSNet

    psnet.ahrq.gov/issue/hiding-plain-sight-resurrecting-power-inspecting-patient
    September 16, 2020 - Commentary Hiding in plain sight—resurrecting the power of inspecting the patient. Citation Text: Gupta S, Saint S, Detsky AS. Hiding in Plain Sight-Resurrecting the Power of Inspecting the Patient. JAMA Intern Med. 2017;177(6):757-758. doi:10.1001/jamainternmed.2017.0634. Copy Citatio…

  15. The Johns Hopkins Hospital: identifying and addressing risks and safety issues. | PSNet

    psnet.ahrq.gov/issue/johns-hopkins-hospital-identifying-and-addressing-risks-and-safety-issues
    January 06, 2017 - Commentary The Johns Hopkins Hospital: identifying and addressing risks and safety issues. Citation Text: Paine LA, Baker DR, Rosenstein BJ, et al. The Johns Hopkins Hospital: identifying and addressing risks and safety issues. Jt Comm J Qual Saf. 2004;30(10):543-50. Copy Citation …

  16. Medical error, incident investigation and the second victim: doing better but feeling worse? | PSNet

    psnet.ahrq.gov/issue/medical-error-incident-investigation-and-second-victim-doing-better-feeling-worse
    July 29, 2020 - Commentary Medical error, incident investigation and the second victim: doing better but feeling worse? Citation Text: Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf. 2012;21(4):267-70. doi:10.1136/bmjqs-20…

  17. Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry. | PSNet

    psnet.ahrq.gov/issue/evidence-based-red-cell-transfusion-critically-ill-quality-improvement-using-computerized
    February 15, 2017 - Study Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry. Citation Text: Rana R, Afessa B, Keegan MT, et al. Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician …

  18. Prescribing errors in children: why they happen and how to prevent them. | PSNet

    psnet.ahrq.gov/issue/prescribing-errors-children-why-they-happen-and-how-prevent-them
    December 13, 2017 - Newspaper/Magazine Article Prescribing errors in children: why they happen and how to prevent them. Citation Text: Conn R, Fox A, Carrington A, et al. Prescribing errors in children: why they happen and how to prevent them. Pharmaceutical Journal. 2023;310:7973. doi:10.1211/pj.2023.1.184…

  19. Guided prescription of psychotropic medications for geriatric inpatients. | PSNet

    psnet.ahrq.gov/issue/guided-prescription-psychotropic-medications-geriatric-inpatients
    February 04, 2018 - Study Guided prescription of psychotropic medications for geriatric inpatients. Citation Text: Peterson JF, Kuperman GJ, Shek C, et al. Guided prescription of psychotropic medications for geriatric inpatients. Arch Intern Med. 2005;165(7):802-7. Copy Citation Format: Goog…

  20. The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths. | PSNet

    psnet.ahrq.gov/issue/clinical-transformation-ascension-health-eliminating-all-preventable-injuries-and-deaths
    January 05, 2017 - Commentary The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths. Citation Text: Pryor DB, Tolchin SF, Hendrich A, et al. The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths. Jt Comm J Qual Patient Sa…
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