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  1. Deafening silence? Time to reconsider whether organisations are silent or deaf when things go wrong. | PSNet

    psnet.ahrq.gov/issue/deafening-silence-time-reconsider-whether-organisations-are-silent-or-deaf-when-things-go
    August 24, 2016 - Commentary Deafening silence? Time to reconsider whether organisations are silent or deaf when things go wrong. Citation Text: Jones A, Kelly D. Deafening silence? Time to reconsider whether organisations are silent or deaf when things go wrong. BMJ Qual Saf. 2014;23(9):709-13. doi:10.11…

  2. SEIPS 101 and seven simple SEIPS tools. | PSNet

    psnet.ahrq.gov/issue/seips-101-and-seven-simple-seips-tools
    October 03, 2013 - Commentary SEIPS 101 and seven simple SEIPS tools. Citation Text: Holden RJ, Carayon P. SEIPS 101 and seven simple SEIPS tools. BMJ Qual Saf. 2021;30(11):901-910. doi:10.1136/bmjqs-2020-012538. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

  3. Randomized Controlled Trial Embedded in an Electronic Health Record - 2011 | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/randomized-controlled-trial-embedded-electronic-health-record/annual-summary/2011
    January 01, 2011 - Randomized Controlled Trial Embedded in an Electronic Health Record - 2011 Project Name Randomized Controlled Trial Embedded in an Electronic Health Record Principal Investigator Kahn, James Organization University of California, San Francisco Funding Mechanism RFA:…

  4. Patient-initiated second opinions: systematic review of characteristics and impact on diagnosis, treatment, and satisfaction. | PSNet

    psnet.ahrq.gov/issue/patient-initiated-second-opinions-systematic-review-characteristics-and-impact-diagnosis
    May 29, 2015 - Review Patient-initiated second opinions: systematic review of characteristics and impact on diagnosis, treatment, and satisfaction. Citation Text: Payne VL, Singh H, Meyer AND, et al. Patient-Initiated Second Opinions: Systematic Review of Characteristics and Impact on Diagnosis, Treatm…

  5. Blink or think: can further reflection improve initial diagnostic impressions? | PSNet

    psnet.ahrq.gov/issue/blink-or-think-can-further-reflection-improve-initial-diagnostic-impressions
    November 28, 2012 - Study Blink or think: can further reflection improve initial diagnostic impressions? Citation Text: Hess BJ, Lipner RS, Thompson V, et al. Blink or think: can further reflection improve initial diagnostic impressions? Acad Med. 2015;90(1):112-118. doi:10.1097/ACM.0000000000000550. Copy…

  6. Anatomy of an incident disclosure: the importance of dialogue. | PSNet

    psnet.ahrq.gov/issue/anatomy-incident-disclosure-importance-dialogue
    February 20, 2012 - Commentary Anatomy of an incident disclosure: the importance of dialogue. Citation Text: Iedema R, Allen S. Anatomy of an incident disclosure: the importance of dialogue. Jt Comm J Qual Patient Saf. 2012;38(10):435-42. Copy Citation Format: Google Scholar PubMed BibTeX En…

  7. Reporting and disclosing medical errors: pediatricians' attitudes and behaviors. | PSNet

    psnet.ahrq.gov/issue/reporting-and-disclosing-medical-errors-pediatricians-attitudes-and-behaviors
    April 30, 2014 - Study Reporting and disclosing medical errors: pediatricians' attitudes and behaviors. Citation Text: Garbutt J, Brownstein DR, Klein EJ, et al. Reporting and disclosing medical errors: pediatricians' attitudes and behaviors. Arch Pediatr Adolesc Med. 2007;161(2):179-85. Copy Citatio…

  8. Nurses relate the contributing factors involved in medication errors. | PSNet

    psnet.ahrq.gov/issue/nurses-relate-contributing-factors-involved-medication-errors
    February 18, 2009 - Study Nurses relate the contributing factors involved in medication errors. Citation Text: Tang F-I, Sheu S-J, Yu S, et al. Nurses relate the contributing factors involved in medication errors. J Clin Nurs. 2007;16(3):447-57. Copy Citation Format: Google Scholar PubMed Bi…

  9. Misdiagnosis of heart failure: a systematic review of the literature. | PSNet

    psnet.ahrq.gov/issue/misdiagnosis-heart-failure-systematic-review-literature
    October 06, 2021 - Review Misdiagnosis of heart failure: a systematic review of the literature. Citation Text: Wong CW, Tafuro J, Azam Z, et al. Misdiagnosis of heart failure: a systematic review of the literature. J Cardiac Failure. 2021;27(9):925-933. doi:10.1016/j.cardfail.2021.05.014. Copy Citation …

  10. Interrogating and uprooting systemic racism in the emergency department. | PSNet

    psnet.ahrq.gov/issue/interrogating-and-uprooting-systemic-racism-emergency-department
    March 05, 2025 - Commentary Interrogating and uprooting systemic racism in the emergency department. Citation Text: Sangal RB, Khidir H, Agarwal AK. Interrogating and uprooting systemic racism in the emergency department. JAMA Health Forum. 2024;5(8):e242347. doi:10.1001/jamahealthforum.2024.2347. Copy…

  11. Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships? | PSNet

    psnet.ahrq.gov/issue/duty-hour-limits-and-patient-care-and-resident-outcomes-can-high-quality-studies-offer
    July 10, 2017 - Review Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships? Citation Text: Philibert I, Nasca TJ, Brigham T, et al. Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into…

  12. Compliance with the WHO Surgical Safety Checklist: deviations and possible improvements. | PSNet

    psnet.ahrq.gov/issue/compliance-who-surgical-safety-checklist-deviations-and-possible-improvements
    September 29, 2017 - Study Compliance with the WHO Surgical Safety Checklist: deviations and possible improvements. Citation Text: Rydenfält C, Johansson G, Odenrick P, et al. Compliance with the WHO Surgical Safety Checklist: deviations and possible improvements. Int J Qual Health Care. 2013;25(2):182-187. …

  13. Identifying and measuring administrative harms experienced by hospitalists and administrative leaders. | PSNet

    psnet.ahrq.gov/issue/identifying-and-measuring-administrative-harms-experienced-hospitalists-and-administrative
    April 12, 2023 - Study Identifying and measuring administrative harms experienced by hospitalists and administrative leaders. Citation Text: Burden M, Astik GJ, Auerbach AD, et al. Identifying and measuring administrative harms experienced by hospitalists and administrative leaders. JAMA Intern Med. 2024…

  14. Psychosocial factors and safety in high-risk industries: a systematic literature review. | PSNet

    psnet.ahrq.gov/issue/psychosocial-factors-and-safety-high-risk-industries-systematic-literature-review
    July 15, 2020 - Review Psychosocial factors and safety in high-risk industries: a systematic literature review. Citation Text: Derdowski LA, Mathisen GE. Psychosocial factors and safety in high-risk industries: a systematic literature review. Safety Sci. 2022;157:105948. doi:10.1016/j.ssci.2022.105948. …

  15. Diet order entry by registered dietitians results in a reduction in error rates and time delays compared with other health professionals. | PSNet

    psnet.ahrq.gov/issue/diet-order-entry-registered-dietitians-results-reduction-error-rates-and-time-delays-compared
    September 23, 2020 - Study Diet order entry by registered dietitians results in a reduction in error rates and time delays compared with other health professionals. Citation Text: Imfeld K, Keith M, Stoyanoff L, et al. Diet order entry by registered dietitians results in a reduction in error rates and time …

  16. An observational study of medication administration errors in old-age psychiatric inpatients. | PSNet

    psnet.ahrq.gov/issue/observational-study-medication-administration-errors-old-age-psychiatric-inpatients
    September 27, 2017 - Study An observational study of medication administration errors in old-age psychiatric inpatients. Citation Text: Haw C, Stubbs J, Dickens G. An observational study of medication administration errors in old-age psychiatric inpatients. Int J Qual Health Care. 2007;19(4):210-6. Copy Ci…

  17. Structured patient handoff on an internal medicine ward: a cluster randomized control trial. | PSNet

    psnet.ahrq.gov/issue/structured-patient-handoff-internal-medicine-ward-cluster-randomized-control-trial
    September 23, 2020 - Study Structured patient handoff on an internal medicine ward: a cluster randomized control trial. Citation Text: Tam P, Nijjar AP, Fok M, et al. Structured patient handoff on an internal medicine ward: A cluster randomized control trial. PLoS One. 2018;13(4):e0195216. doi:10.1371/journa…

  18. Ten years of incident reports on in-hospital cardiac arrest - Are they useful for improvements? | PSNet

    psnet.ahrq.gov/issue/ten-years-incident-reports-hospital-cardiac-arrest-are-they-useful-improvements
    January 26, 2022 - Study Ten years of incident reports on in-hospital cardiac arrest - Are they useful for improvements? Citation Text: Djärv T. Ten years of incident reports on in-hospital cardiac arrest – Are they useful for improvements? Resusc Plus. 2023;17:100525. doi:10.1016/j.resplu.2023.100525. C…

  19. Interventions to improve communication at hospital discharge and rates of readmission: a systematic review and meta-analysis. | PSNet

    psnet.ahrq.gov/issue/interventions-improve-communication-hospital-discharge-and-rates-readmission-systematic
    January 12, 2022 - Review Interventions to improve communication at hospital discharge and rates of readmission: a systematic review and meta-analysis. Citation Text: Becker C, Zumbrunn S, Beck K, et al. Interventions to improve communication at hospital discharge and rates of readmission. JAMA Netw Open. …

  20. Defining and classifying terminology for medication harm: a call for consensus. | PSNet

    psnet.ahrq.gov/issue/defining-and-classifying-terminology-medication-harm-call-consensus
    June 22, 2022 - Review Defining and classifying terminology for medication harm: a call for consensus. Citation Text: Falconer N, Barras M, Martin J, et al. Defining and classifying terminology for medication harm: a call for consensus. Eur J Clin Pharmacol. 2019;75(2):137-145. doi:10.1007/s00228-018-25…
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