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  1. psnet.ahrq.gov/issue/there-no-such-thing-nonjudgmental-debriefing-theory-and-method-debriefing-good-judgment
    December 19, 2014 - Commentary There is no such thing as a "nonjudgmental" debriefing: a theory and method for debriefing with good judgment. Citation Text: Rudolph JW, Simon R, Dufresne RL, et al. There's no such thing as "nonjudgmental" debriefing: a theory and method for debriefing with good judgment. Si…
  2. psnet.ahrq.gov/issue/vanishing-nonforensic-autopsy
    February 09, 2011 - Commentary The vanishing nonforensic autopsy. Citation Text: Shojania KG, Burton EC. The vanishing nonforensic autopsy. N Engl J Med. 2008;358(9):873-5. doi:10.1056/NEJMp0707996. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …
  3. psnet.ahrq.gov/issue/using-medical-malpractice-closed-claims-data-reduce-surgical-risk-and-improve-patient-safety
    December 01, 2010 - Commentary Using medical malpractice closed claims data to reduce surgical risk and improve patient safety. Citation Text: Manuel BM, Greenwald LM. Using medical malpractice closed claims data to reduce surgical risk and improve patient safety. Bull Am Coll Surg. 2007;92(3):27-30. Copy…
  4. psnet.ahrq.gov/issue/checklists-safety-my-culture-and-me
    June 19, 2019 - Commentary Checklists, safety, my culture and me. Citation Text: Raghunathan K. Checklists, safety, my culture and me. BMJ Qual Saf. 2012;21(7):617-20. doi:10.1136/bmjqs-2011-000608. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endno…
  5. psnet.ahrq.gov/issue/national-healthcare-system-action-alliance-advance-patient-safety
    April 01, 2024 - Multi-use Website The National Healthcare System Action Alliance for Patient and Workforce Safety. Citation Text: The National Healthcare System Action Alliance for Patient and Workforce Safety. US Department of Health and Human Services. Copy Citation Save Save t…
  6. psnet.ahrq.gov/issue/evolving-hospital-quality-star-rating-system-cms-aligning-stars
    December 13, 2017 - Commentary An evolving hospital quality star rating system from CMS: aligning the stars. Citation Text: Bilimoria KY, Barnard C. An evolving hospital quality star rating system from CMS: aligning the stars. JAMA. 2021;325(21):2151-2152. doi:10.1001/jama.2021.6946. Copy Citation For…
  7. psnet.ahrq.gov/issue/role-automation-complex-system-failures
    June 28, 2013 - Commentary The role of automation in complex system failures. Citation Text: Perry SJ, Wears RL, Cook RI. The role of automation in complex system failures. J Patient Saf. 2005;1(1):56-61. https://journals.lww.com/journalpatientsafety/Fulltext/2005/03000/The_Role_of_Automation_in_Compl…
  8. psnet.ahrq.gov/issue/survey-results-pharmacists-provide-support-enhance-organizational-response-codes
    November 02, 2022 - Newspaper/Magazine Article Survey results from pharmacists provide support to enhance the organizational response to codes. Citation Text: Survey results from pharmacists provide support to enhance the organizational response to codes. ISMP Medication Safety Alert! Acute care edition. Oc…
  9. psnet.ahrq.gov/issue/measurement-and-training-teamstepps-dimensions-using-medical-team-performance-assessment-tool
    March 09, 2009 - Commentary Measurement and training of TeamSTEPPS dimensions using the Medical Team Performance Assessment Tool. Citation Text: Lineberry M, Bryan E, Brush T, et al. Measurement and training of TeamSTEPPS dimensions using the Medical Team Performance Assessment Tool. Jt Comm J Qual Pat…
  10. psnet.ahrq.gov/issue/make-no-mistake-about-it-chain-pharmacies-are-finding-innovative-ways-combat-medication
    May 20, 2020 - Newspaper/Magazine Article Make no mistake about it: chain pharmacies are finding innovative ways to combat medication errors. Citation Text: Make no mistake about it: chain pharmacies are finding innovative ways to combat medication errors. Levy S. Drug Topics. July 9, 2007 Copy…
  11. psnet.ahrq.gov/issue/documenting-day-discussion-ahead-crest-wave-creating-national-agenda-systemic-change-enhanced
    April 28, 2021 - Book/Report Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change for Enhanced Clinician Well-Being. Citation Text: Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change …
  12. psnet.ahrq.gov/issue/junior-doctors-shifts-and-sleep-deprivation
    October 16, 2012 - Commentary Junior doctors' shifts and sleep deprivation. Citation Text: Murray A, Pounder R, Mather H, et al. Junior doctors' shifts and sleep deprivation. BMJ. 2005;330(7505):1404. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
  13. psnet.ahrq.gov/issue/toolkit-preventing-clabsi-and-cauti-icus
    December 24, 2008 - Toolkit Toolkit for Preventing CLABSI and CAUTI in ICUs. Citation Text: Toolkit for Preventing CLABSI and CAUTI in ICUs. Rockville, MD: Agency for Healthcare Research and Quality; April 2022. Copy Citation Save Save to your library Print Download PDF …
  14. psnet.ahrq.gov/issue/adverse-events-toolkit-medical-record-review-methodology
    July 19, 2023 - Book/Report Adverse Events Toolkit: Medical Record Review Methodology. Citation Text: Adverse Events Toolkit: Medical Record Review Methodology. Maxwell A. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2023. Report no. OEI-06-21-00…
  15. psnet.ahrq.gov/issue/eau-policy-live-surgery-events
    December 29, 2014 - Review EAU policy on live surgery events. Citation Text: Artibani W, Ficarra V, Challacombe BJ, et al. EAU policy on live surgery events. Eur Urol. 2014;66(1):87-97. doi:10.1016/j.eururo.2014.01.028. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndN…
  16. psnet.ahrq.gov/issue/system-failure-versus-personal-accountability-case-clean-hands
    February 16, 2011 - Commentary System failure versus personal accountability--the case for clean hands. Citation Text: Goldmann DA. System failure versus personal accountability--the case for clean hands. N Engl J Med. 2006;355(2):121-3. Copy Citation Format: Google Scholar PubMed BibTeX End…
  17. psnet.ahrq.gov/issue/transformation-health-care-front-line
    July 24, 2017 - Commentary Transformation of health care at the front line. Citation Text: Conway PH, Clancy CM. Transformation of health care at the front line. JAMA. 2009;301(7):763-5. doi:10.1001/jama.2009.103. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndN…
  18. psnet.ahrq.gov/issue/err-human-apologize-hard
    September 28, 2022 - Commentary To err is human, to apologize is hard. Citation Text: Krakower TM. To err Is human, to apologize is hard. JAMA. 2021;326(3):223-224. doi:10.1001/jama.2021.10840. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
  19. psnet.ahrq.gov/issue/appropriate-prescribing-medications-eight-step-approach
    January 10, 2024 - Commentary Appropriate prescribing of medications: an eight-step approach. Citation Text: Pollock M, Bazaldua O, Dobbie AE. Appropriate prescribing of medications: an eight-step approach. Am Fam Physician. 2007;75(2):231-236. Copy Citation Format: Google Scholar PubMed Bi…
  20. psnet.ahrq.gov/issue/workarounds-are-routinely-used-nurses-are-they-ethical
    October 27, 2016 - Commentary Workarounds are routinely used by nurses—but are they ethical? Citation Text: Berlinger N. Workarounds Are Routinely Used by Nurses-But Are They Ethical? Am J Nurs. 2017;117(10):53-55. doi:10.1097/01.NAJ.0000525875.82101.b7. Copy Citation Format: DOI Google Schol…

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