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psnet.ahrq.gov/issue/survey-nurses-experiences-applying-joint-commissions-medication-management-titration
September 15, 2021 - Study
Survey of nurses' experiences applying The Joint Commission's medication management titration standards.
Citation Text:
Davidson JE, Doran N, Petty A, et al. Survey of nurses' experiences applying The Joint Commission's medication management titration standards. Am J Crit Care. 202…
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psnet.ahrq.gov/issue/women-large-vessel-occlusion-acute-ischemic-stroke-are-less-likely-be-routed-comprehensive
October 12, 2022 - Study
Women with large vessel occlusion acute ischemic stroke are less likely to be routed to comprehensive stroke centers.
Citation Text:
Tariq MB, Ali I, Salazar‐Marioni S, et al. Women with large vessel occlusion acute ischemic stroke are less likely to be routed to comprehensive stro…
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psnet.ahrq.gov/issue/evaluating-iatrogenic-prescribing-development-oncology-focused-trigger-tool
December 23, 2020 - Study
Evaluating iatrogenic prescribing: development of an oncology-focused trigger tool.
Citation Text:
Hébert G, Netzer F, Ferrua M, et al. Evaluating iatrogenic prescribing: development of an oncology-focused trigger tool. Eur J Cancer. 2015;51(3):427-35. doi:10.1016/j.ejca.2014.12.00…
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psnet.ahrq.gov/issue/study-multisite-prospective-adverse-event-surveillance-system
October 16, 2019 - Study
Study of a multisite prospective adverse event surveillance system.
Citation Text:
Forster AJ, Huang A, Lee TC, et al. Study of a multisite prospective adverse event surveillance system. BMJ Qual Saf. 2020;29(4). doi:10.1136/bmjqs-2018-008664.
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DO…
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psnet.ahrq.gov/issue/will-covid-19-pandemic-transform-infection-prevention-and-control-surgery-seeking-leverage
February 09, 2022 - Commentary
Will the COVID-19 pandemic transform infection prevention and control in surgery? Seeking leverage points for organizational learning.
Citation Text:
Will the COVID-19 pandemic transform infection prevention and control in surgery? Seeking leverage points for organizational le…
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psnet.ahrq.gov/issue/disruptive-behavior-inherent-surgeon-or-environment-analysis-314-events-single-academic
October 19, 2022 - Study
Is disruptive behavior inherent to the surgeon or the environment? Analysis of 314 events at a single academic medical center.
Citation Text:
Heslin MJ, Singletary BA, Benos KC, et al. Is Disruptive Behavior Inherent to the Surgeon or the Environment? Analysis of 314 Events at a Si…
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psnet.ahrq.gov/issue/promises-project
January 30, 2019 - Multi-use Website
The PROMISES Project.
Citation Text:
The PROMISES Project. Brigham and Women's Hospital; Institute for Healthcare Improvement; Massachusetts Coalition for the Prevention of Medical Errors; Coverys; CRICO; Harvard School of Public Health; Harvard Medical School; Health…
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psnet.ahrq.gov/issue/evaluating-clinical-decision-support-systems-monitoring-cpoe-order-check-override-rates
October 19, 2022 - Study
Evaluating clinical decision support systems: monitoring CPOE order check override rates in the Department of Veterans Affairs' computerized patient record system.
Citation Text:
Lin C-P, Payne TH, Nichol P, et al. Evaluating clinical decision support systems: monitoring CPOE ord…
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psnet.ahrq.gov/issue/examining-medication-ordering-errors-using-ahrq-network-patient-safety-databases
November 30, 2022 - Study
Examining medication ordering errors using AHRQ Network of Patient Safety Databases.
Citation Text:
Grauer A, Rosen A, Applebaum JR, et al. Examining medication ordering errors using AHRQ network of patient safety databases. J Am Med Inform Assoc. 2023;30(5):838-845. doi:10.1093/ja…
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psnet.ahrq.gov/issue/effect-multispecialty-faculty-handoff-initiative-safety-culture-and-handoff-quality
March 10, 2019 - Study
Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality.
Citation Text:
Fitzgerald KM, Banerjee TR, Starmer AJ, et al. Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality. Pediatr Qual Saf. 2022;7(2):e539. …
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psnet.ahrq.gov/issue/physician-scores-national-clinical-skills-examination-predictors-complaints-medical
October 16, 2019 - Study
Classic
Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities.
Citation Text:
Tamblyn R, Abrahamowicz M, Dauphinee D, et al. Physician scores on a national clinical skills examination as …
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psnet.ahrq.gov/issue/improving-safety-evaluating-impact-supply-chain-and-drug-shortages-health-systems
November 04, 2020 - Commentary
Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems.
Citation Text:
Patel V, Cieslak K, Hertig JB. Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems. Hosp Pharm. 2023;58(2):120-124.…
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Retained Surgical Items: Causation and Prevention
February 26, 2025
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
Background
A retained surgical item (RSI) is a surgical patient safety pro…
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - The efficient and effective integration of evidence-based decision support systems within CPOE is a necessary
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psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
November 01, 2012 - unlikely to be seen soon, but creating it will be a key intervention if we are to promote safe and efficient
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psnet.ahrq.gov/web-mm/or
August 22, 2013 - Safeguards, like briefings, can be very time efficient investments, as they dramatically reduce the frequency
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psnet.ahrq.gov/issue/creation-and-impact-dedicated-section-quality-and-patient-safety-clinical-academic-department
May 28, 2008 - Commentary
The creation and impact of a dedicated section on quality and patient safety in a clinical academic department.
Citation Text:
Boudreaux AM, Vetter TR. The Creation and Impact of a Dedicated Section on Quality and Patient Safety in a Clinical Academic Department. Academic Medi…
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psnet.ahrq.gov/issue/investigating-prevalence-and-causes-prescribing-errors-general-practice-practice-study
May 24, 2015 - Book/Report
Investigating the Prevalence and Causes of Prescribing Errors in General Practice: The PRACtICe Study.
Citation Text:
Investigating the Prevalence and Causes of Prescribing Errors in General Practice: The PRACtICe Study. Avery T, Barber N, Ghaleb M, et al. London, UK: Gener…
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psnet.ahrq.gov/issue/quality-safety-time-coronavirus-design-better-learn-faster
March 29, 2017 - Commentary
Quality & safety in the time of coronavirus--design better, learn faster.
Citation Text:
Fitzsimons J. Quality and safety in the time of Coronavirus: design better, learn faster. Int J Qual Health Care. 2021;33(1):mzaa051. doi:10.1093/intqhc/mzaa051.
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psnet.ahrq.gov/issue/implementation-patient-centeredness-enhance-patient-safety
June 24, 2010 - Commentary
Implementation of patient centeredness to enhance patient safety.
Citation Text:
Berntsen KJ. Implementation of patient centeredness to enhance patient safety. J Nurs Care Qual. 2006;21(1):15-19.
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