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Capturing essential information to achieve safe interoperability. | PSNet

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February 23, 2015 - Commentary Capturing essential information to achieve safe interoperability. Citation Text: Weininger S, Jaffe MB, Rausch T, et al. Capturing Essential Information to Achieve Safe Interoperability. Anesth Analg. 2017;124(1):83-94. Copy Citation Format: Google Scholar PubMed…

Improving the quality of health care: what's taking so long? | PSNet

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April 06, 2016 - Commentary Classic Improving the quality of health care: what's taking so long? Citation Text: Chassin MR. Improving The Quality Of Health Care: What’s Taking So Long? Health Aff. 2013;32(10):1761-1765. doi:10.1377/hlthaff.2013.0809. Copy Citation Format: …

Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue. | PSNet

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January 27, 2016 - Commentary Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue. Citation Text: Young JQ, Wachter R. Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue. JAMA.…

The WHO World Alliance for Patient Safety: a new challenge or an old one neglected? | PSNet

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February 14, 2024 - Commentary The WHO World Alliance for Patient Safety: a new challenge or an old one neglected? Citation Text: Edwards R. The WHO World Alliance for Patient Safety: a new challenge or an old one neglected? Drug Saf. 2005;28(5):379-86. Copy Citation Format: Google Scholar P…

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May 23, 2025 - Privacy Policy Thank you for visiting AHRQ PSNet. The site is produced by an editorial team at the University of California, Davis under a contract from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. We collect no personal information about you when you visit …

AI: promise or peril for patient safety. | PSNet

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July 20, 2022 - Commentary AI: promise or peril for patient safety. Citation Text: Ullem BD, Hatlie MJ, Lounsbury O. AI: promise or peril for patient safety. J Patient Saf. 2025;21(1):34-37. doi:10.1097/pts.0000000000001301. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML En…

Expert consensus on currently accepted measures of harm. | PSNet

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January 25, 2023 - Commentary Expert consensus on currently accepted measures of harm. Citation Text: Logan MS, Myers LC, Salmasian H, et al. Expert consensus on currently accepted measures of harm. J Patient Saf. 2021;17(8):e1726-e1731. doi:10.1097/pts.0000000000000754. Copy Citation Format: …

An invisible disability: communication, patient safety and dual sensory impairment in older persons. | PSNet

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July 01, 2019 - Commentary An invisible disability: communication, patient safety and dual sensory impairment in older persons. Citation Text: Dunsmore ME, Watharow A, Schneider J. An invisible disability: communication, patient safety and dual sensory impairment in older persons. J Adv Nurs. 2024;Epub …

Medication administration in aged care facilities: a mixed-methods systematic review. | PSNet

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July 31, 2024 - Review Medication administration in aged care facilities: a mixed-methods systematic review. Citation Text: Garratt S, Dowling A, Manias E. Medication administration in aged care facilities: a mixed‐methods systematic review. J Adv Nurs. 2025;81(2):621-640. doi:10.1111/jan.16318. Copy …

Implementation, Adoption, and Scaling Workgroup: Landscape Assessment on the Use of Artificial Intelligence to Scale PC CDS. | PSNet

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December 01, 2017 - Book/Report Implementation, Adoption, and Scaling Workgroup: Landscape Assessment on the Use of Artificial Intelligence to Scale PC CDS. Citation Text: Kawamoto K, Greysen SR, Heaney-Huls K, et al. Implementation, Adoption, And Scaling Workgroup: Landscape Assessment On The Use Of Artifi…

Towards safer transitions: a curriculum to teach and assess hospital-to-hospice handoffs. | PSNet

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March 20, 2024 - Commentary Towards safer transitions: a curriculum to teach and assess hospital-to-hospice handoffs. Citation Text: Darrah NJ, O'Connor NR. Toward Safer Transitions: A Curriculum to Teach and Assess Hospital-to-Hospice Handoffs. J Pain Symptom Manage. 2016;51(6):959-962.e2. doi:10.1016/j…

Teaching nursing students the ethical and legal consequences of medical errors: insights from the RaDonda Vaught case using the jigsaw technique. | PSNet

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July 05, 2017 - Study Teaching nursing students the ethical and legal consequences of medical errors: insights from the RaDonda Vaught case using the jigsaw technique. Citation Text: Geiselman EL, Opsahl A, Townsend C. Teaching nursing students the ethical and legal consequences of medical errors: insig…

The critical need for nursing education to address the diagnostic process. | PSNet

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June 08, 2022 - Commentary The critical need for nursing education to address the diagnostic process. Citation Text: Gleason KT, Harkless G, Stanley J, et al. The critical need for nursing education to address the diagnostic process. Nurs Outlook. 2021;69(3):362-369. doi:10.1016/j.outlook.2020.12.005. …

Patient engagement in health care safety: an overview of mixed-quality evidence. | PSNet

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October 21, 2020 - Review Emerging Classic Patient engagement in health care safety: an overview of mixed-quality evidence. Citation Text: Sharma AE, Rivadeneira NA, Barr-Walker J, et al. Patient Engagement In Health Care Safety: An Overview Of Mixed-Quality Evidence. Health Aff (…

Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023. | PSNet

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July 07, 2021 - Commentary Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023. Citation Text: Wu AW, Papieva I, Sheridan S, et al. Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023. J Patient Saf R…

Using computerized prescriber order entry to limit overrides from automated dispensing cabinets. | PSNet

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May 18, 2022 - Commentary Using computerized prescriber order entry to limit overrides from automated dispensing cabinets. Citation Text: Drake E, Srinivas P, Trujillo T. Using computerized prescriber order entry to limit overrides from automated dispensing cabinets. Am J Health-Syst Pharm. 2016;73(14)…

Shift-to-shift handoff effects on patient safety and outcomes: a systematic review. | PSNet

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January 22, 2016 - Review Shift-to-shift handoff effects on patient safety and outcomes: a systematic review. Citation Text: Mardis M, Davis JJ, Benningfield B, et al. Shift-to-Shift Handoff Effects on Patient Safety and Outcomes. Am J Med Qual. 2017;32(1):34-42. doi:10.1177/1062860615612923. Copy Citati…

The Lancet Commission on lessons for the future from the COVID-19 pandemic. | PSNet

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January 12, 2022 - Commentary The Lancet Commission on lessons for the future from the COVID-19 pandemic. Citation Text: Sachs JD, Karim SSA, Aknin L, et al. The Lancet Commission on lessons for the future from the COVID-19 pandemic. Lancet. 2022;400(10359):1224-1280. doi:10.1016/s0140-6736(22)01585-9. C…

The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception towards Co-Design. | PSNet

psnet.ahrq.gov/issue/patients-role-diagnostic-safety-and-excellence-passive-reception-towards-co-design

April 10, 2019 - Book/Report The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception towards Co-Design. Citation Text: Epstein HM, Haskell H, Hemmelgarn C, et al. The Patient’s Role In Diagnostic Safety And Excellence: From Passive Reception Towards Co-Design. Rockville, MD: Agency…

Preventing medication errors in transitions of care: a patient case approach. | PSNet

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October 17, 2012 - Review Preventing medication errors in transitions of care: a patient case approach. Citation Text: Johnson A, Guirguis E, Grace Y. Preventing medication errors in transitions of care: A patient case approach. J Am Pharm Assoc (2003). 2015;55(2):e264-276. doi:10.1331/JAPhA.2015.15509. …

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