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  1. From a blame culture to a just culture in health care. | PSNet

    psnet.ahrq.gov/issue/blame-culture-just-culture-health-care
    January 23, 2017 - Commentary From a blame culture to a just culture in health care. Citation Text: Khatri N, Brown GD, Hicks LL. From a blame culture to a just culture in health care. Health Care Manag Rev. 2009;34(4):312-322. doi:10.1097/HMR.0b013e3181a3b709. Copy Citation Format: DOI Goog…

  2. Junior doctors and patient safety: evaluating knowledge, attitudes and perception of safety climate. | PSNet

    psnet.ahrq.gov/issue/junior-doctors-and-patient-safety-evaluating-knowledge-attitudes-and-perception-safety
    February 18, 2019 - Study Junior doctors and patient safety: evaluating knowledge, attitudes and perception of safety climate. Citation Text: Durani P, Dias J, Singh HP, et al. Junior doctors and patient safety: evaluating knowledge, attitudes and perception of safety climate. BMJ Qual Saf. 2013;22(1):65-…

  3. Rapid response systems in the Netherlands. | PSNet

    psnet.ahrq.gov/issue/rapid-response-systems-netherlands
    November 20, 2015 - Study Rapid response systems in the Netherlands. Citation Text: Ludikhuize J, Hamming A, De Jonge E, et al. Rapid Response Systems in the Netherlands. Jt Comm J Qual Patient Saf. 2016;37(3):138-149. doi:10.1016/s1553-7250(11)37017-1. Copy Citation Format: DOI Google Schol…

  4. The impact of RVU-based compensation on patient safety outcomes in outpatient otolaryngology procedures. | PSNet

    psnet.ahrq.gov/issue/impact-rvu-based-compensation-patient-safety-outcomes-outpatient-otolaryngology-procedures
    October 19, 2022 - Study The impact of RVU-based compensation on patient safety outcomes in outpatient otolaryngology procedures. Citation Text: Stanisce L, Ahmad N, Deckard N, et al. The Impact of RVU-Based Compensation on Patient Safety Outcomes in Outpatient Otolaryngology Procedures. Otolaryngol Head N…

  5. Realizing e-prescribing's potential to reduce outpatient psychiatric medication errors. | PSNet

    psnet.ahrq.gov/issue/realizing-e-prescribings-potential-reduce-outpatient-psychiatric-medication-errors
    November 12, 2014 - Commentary Realizing e-prescribing's potential to reduce outpatient psychiatric medication errors. Citation Text: Hirschtritt ME, Chan S, Ly WO. Realizing E-Prescribing's Potential to Reduce Outpatient Psychiatric Medication Errors. Psychiatr Serv. 2018;69(2):129-132. doi:10.1176/appi.ps…

  6. Video registration of trauma team performance in the emergency department: the results of a 2-year analysis in a Level 1 trauma center. | PSNet

    psnet.ahrq.gov/issue/video-registration-trauma-team-performance-emergency-department-results-2-year-analysis-level
    November 16, 2022 - Study Video registration of trauma team performance in the emergency department: the results of a 2-year analysis in a Level 1 trauma center. Citation Text: Lubbert PHW, Kaasschieter EG, Hoorntje LE, et al. Video registration of trauma team performance in the emergency department: the …

  7. Optimizing transitions of care to reduce rehospitalizations. | PSNet

    psnet.ahrq.gov/issue/optimizing-transitions-care-reduce-rehospitalizations
    November 04, 2015 - Review Optimizing transitions of care to reduce rehospitalizations. Citation Text: Li J, Young R, Williams M. Optimizing transitions of care to reduce rehospitalizations. Cleve Clin J Med. 2014;81(5):312-20. doi:10.3949/ccjm.81a.13106. Copy Citation Format: DOI Google Schol…

  8. The Patient Safety Leadership Academy at the University of Pennsylvania: the first cohort's learning experience. | PSNet

    psnet.ahrq.gov/issue/patient-safety-leadership-academy-university-pennsylvania-first-cohorts-learning-experience
    October 04, 2011 - Study The Patient Safety Leadership Academy at the University of Pennsylvania: the first cohort's learning experience. Citation Text: Wurster AB, Pearson K, Sonnad SS, et al. The Patient Safety Leadership Academy at the University of Pennsylvania: the first cohort's learning experience…

  9. Recognition and prevention of nosocomial malnutrition: a review and a call to action! | PSNet

    psnet.ahrq.gov/issue/recognition-and-prevention-nosocomial-malnutrition-review-and-call-action
    January 29, 2020 - Review Recognition and prevention of nosocomial malnutrition: a review and a call to action! Citation Text: Kirkland LL, Shaughnessy E. Recognition and Prevention of Nosocomial Malnutrition: A Review and A Call to Action!. Am J Med. 2017;130(12):1345-1350. doi:10.1016/j.amjmed.2017.07.03…

  10. Adoption of order entry with decision support for chronic care by physician organizations. | PSNet

    psnet.ahrq.gov/issue/adoption-order-entry-decision-support-chronic-care-physician-organizations
    October 06, 2011 - Study Adoption of order entry with decision support for chronic care by physician organizations. Citation Text: Simon JS, Rundall TG, Shortell SM. Adoption of order entry with decision support for chronic care by physician organizations. J Am Med Inform Assoc. 2007;14(4):432-9. Copy …

  11. A comparison of the effects of different typographical methods on the recognizability of printed drug names. | PSNet

    psnet.ahrq.gov/issue/comparison-effects-different-typographical-methods-recognizability-printed-drug-names
    May 31, 2011 - Study A comparison of the effects of different typographical methods on the recognizability of printed drug names. Citation Text: Or CKL, Wang H. A comparison of the effects of different typographical methods on the recognizability of printed drug names. Drug Saf. 2014;37(5):351-9. doi:1…

  12. Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check. | PSNet

    psnet.ahrq.gov/issue/look-alike-sound-alike-drugs-review-include-look-alike-packaging-additional-safety-check
    March 24, 2021 - Study Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check. Citation Text: McCoy LK. Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check. Jt Comm J Qual Patient Saf. 2005;31(1):47-53. Copy Citation…

  13. Prevalence and Burden of Healthcare-Associated Infections (HAIs), 2016–2021. HCUP Statistical Brief #313. | PSNet

    psnet.ahrq.gov/issue/prevalence-and-burden-healthcare-associated-infections-hais-2016-2021-hcup-statistical-brief
    December 18, 2024 - Book/Report Prevalence and Burden of Healthcare-Associated Infections (HAIs), 2016–2021. HCUP Statistical Brief #313. Citation Text: Miller MA, Umscheid CA, Dowell J, et al. Prevalence And Burden Of Healthcare-Associated Infections (Hais), 2016–2021. Hcup Statistical Brief #313. Rockvill…

  14. A failure in the medication delivery system-how disclosure and systems investigation improve patient safety. | PSNet

    psnet.ahrq.gov/issue/failure-medication-delivery-system-how-disclosure-and-systems-investigation-improve-patient
    April 03, 2005 - Commentary A failure in the medication delivery system-how disclosure and systems investigation improve patient safety. Citation Text: Lucas SR, Pollak E, Makowski C. A failure in the medication delivery system—how disclosure and systems investigation improve patient safety. J Healthc Ri…

  15. Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices. | PSNet

    psnet.ahrq.gov/issue/novel-use-electronic-whiteboard-operating-room-increases-surgical-team-compliance-pre
    March 20, 2013 - Study Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices. Citation Text: Mainthia R, Lockney T, Zotov A, et al. Novel use of electronic whiteboard in the operating room increases surgical team compliance with p…

  16. 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…

  17. The Veterans Affairs shift change physician-to-physician handoff project. | PSNet

    psnet.ahrq.gov/issue/veterans-affairs-shift-change-physician-physician-handoff-project
    April 30, 2014 - Study The Veterans Affairs shift change physician-to-physician handoff project. Citation Text: Anderson J, Shroff D, Curtis A, et al. The Veterans Affairs shift change physician-to-physician handoff project. Jt Comm J Qual Patient Saf. 2010;36(2):62-71. Copy Citation Format: …

  18. Surgical safety checklist compliance: a job done poorly! | PSNet

    psnet.ahrq.gov/issue/surgical-safety-checklist-compliance-job-done-poorly
    April 25, 2016 - Study Surgical safety checklist compliance: a job done poorly! Citation Text: Sparks EA, Wehbe-Janek H, Johnson RL, et al. Surgical Safety Checklist compliance: a job done poorly!. J Am Coll Surg. 2013;217(5):867-73.e1-3. doi:10.1016/j.jamcollsurg.2013.07.393. Copy Citation Forma…

  19. 037-Ss-Bed-Bathing-Chg-Cloths-Protocol (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/037-ss-bed-bathing-chg-cloths-protocol.docx
    April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Pre-Op Surgical Decolonization Protocol for Staff: Bathing With 2 Percent Chlorhexidine No-Rinse Cloths Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries The following protocol details the process for performing skin decol…

  20. Hospital admissions due to adverse drug reactions: a report from the Boston Collaborative Drug Surveillance Program. | PSNet

    psnet.ahrq.gov/issue/hospital-admissions-due-adverse-drug-reactions-report-boston-collaborative-drug-surveillance
    March 01, 2023 - Study Classic Hospital admissions due to adverse drug reactions: a report from the Boston Collaborative Drug Surveillance Program. Citation Text: Miller RR. Hospital admissions due to adverse drug reactions. A report from the Boston Collaborative Drug Surveill…
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