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  1. Patient falls in the operating room: why is this still a problem in 2024? | PSNet

    psnet.ahrq.gov/issue/patient-falls-operating-room-why-still-problem-2024
    May 08, 2024 - Commentary Patient falls in the operating room: why is this still a problem in 2024? Citation Text: Pellegrino A, Brook K. Patient falls in the operating room: why is this still a problem in 2024? J Patient Saf. 2024;20(6):e87-e90. doi:10.1097/pts.0000000000001248. Copy Citation Fo…

  2. Using the Agency for Healthcare Research and Quality Patient Safety Indicators for targeting nursing quality improvement. | PSNet

    psnet.ahrq.gov/issue/using-agency-healthcare-research-and-quality-patient-safety-indicators-targeting-nursing
    April 03, 2017 - Study Using the Agency for Healthcare Research and Quality Patient Safety Indicators for targeting nursing quality improvement. Citation Text: Zrelak PA, Utter GH, Sadeghi B, et al. Using the Agency for Healthcare Research and Quality patient safety indicators for targeting nursing qua…

  3. Misdiagnosis in the emergency department: time for a system solution. | PSNet

    psnet.ahrq.gov/issue/misdiagnosis-emergency-department-time-system-solution
    March 25, 2020 - Commentary Misdiagnosis in the emergency department: time for a system solution. Citation Text: Edlow JA, Pronovost PJ. Misdiagnosis in the emergency department: time for a system solution. JAMA. 2023;329(8):631-632. doi:10.1001/jama.2023.0577. Copy Citation Format: DOI Goo…

  4. "Black Women Should Not Die Giving Life": The lived experiences of Black women diagnosed with severe maternal morbidity in the United States. | PSNet

    psnet.ahrq.gov/issue/black-women-should-not-die-giving-life-lived-experiences-black-women-diagnosed-severe
    August 17, 2017 - Study "Black Women Should Not Die Giving Life": The lived experiences of Black women diagnosed with severe maternal morbidity in the United States. Citation Text: Post W, Thomas AD, Sutton KM. “Black Women Should Not Die Giving Life”: The lived experiences of Black women diagnosed with s…

  5. Neonatal near-miss audits: a systematic review and a call to action. | PSNet

    psnet.ahrq.gov/issue/neonatal-near-miss-audits-systematic-review-and-call-action
    August 04, 2021 - Review Neonatal near-miss audits: a systematic review and a call to action. Citation Text: Medeiros PB, Bailey C, Pollock D, et al. Neonatal near-miss audits: a systematic review and a call to action. BMC Pediatr. 2023;23(1):573. doi:10.1186/s12887-023-04383-6. Copy Citation Format…

  6. Chasing zero harm in radiation oncology: using pre-treatment peer review. | PSNet

    psnet.ahrq.gov/issue/chasing-zero-harm-radiation-oncology-using-pre-treatment-peer-review
    January 12, 2022 - Commentary Chasing zero harm in radiation oncology: using pre-treatment peer review. Citation Text: Vijayakumar S, Duggar WN, Packianathan S, et al. Chasing Zero Harm in Radiation Oncology: Using Pre-treatment Peer Review. Front Oncol. 2019;9:302. doi:10.3389/fonc.2019.00302. Copy Cita…

  7. Refining a framework to enhance communication in the emergency department during the diagnostic process: an eDelphi approach. | PSNet

    psnet.ahrq.gov/issue/refining-framework-enhance-communication-emergency-department-during-diagnostic-process
    May 08, 2024 - Study Refining a framework to enhance communication in the emergency department during the diagnostic process: an eDelphi approach. Citation Text: Manojlovich M, Bettencourt AP, Mangus CW, et al. Refining a framework to enhance communication in the emergency department during the diagnos…

  8. Health system resilience, accreditation, high-quality care, and continuous quality improvement: what is the destination and how do we get there? | PSNet

    psnet.ahrq.gov/issue/health-system-resilience-accreditation-high-quality-care-and-continuous-quality-improvement
    November 25, 2020 - Commentary Health system resilience, accreditation, high-quality care, and continuous quality improvement: what is the destination and how do we get there? Citation Text: Nicklin W, Greenfield D. Health system resilience, accreditation, high-quality care, and continuous quality improveme…

  9. To catch a killer: electronic sepsis alert tools reaching a fever pitch? | PSNet

    psnet.ahrq.gov/issue/catch-killer-electronic-sepsis-alert-tools-reaching-fever-pitch
    November 15, 2023 - Commentary To catch a killer: electronic sepsis alert tools reaching a fever pitch? Citation Text: Ruppel H, Liu V. To catch a killer: electronic sepsis alert tools reaching a fever pitch? BMJ Qual Saf. 2019;28(9):693-696. doi:10.1136/bmjqs-2019-009463. Copy Citation Format: …

  10. Clinical reasoning of a generative artificial intelligence model compared with physicians. | PSNet

    psnet.ahrq.gov/issue/clinical-reasoning-generative-artificial-intelligence-model-compared-physicians
    November 13, 2024 - Study Clinical reasoning of a generative artificial intelligence model compared with physicians. Citation Text: Cabral S, Restrepo D, Kanjee Z, et al. Clinical reasoning of a generative artificial intelligence model compared with physicians. JAMA Intern Med. 2024;184(5):581-583. doi:10.1…

  11. Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication. | PSNet

    psnet.ahrq.gov/issue/improving-follow-abnormal-cancer-screens-using-electronic-health-records-trust-verify-test
    July 14, 2010 - Study Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication. Citation Text: Singh H, Wilson L, Petersen L, et al. Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test r…

  12. Ten strategies to improve management of abnormal test result alerts in the electronic health record. | PSNet

    psnet.ahrq.gov/issue/ten-strategies-improve-management-abnormal-test-result-alerts-electronic-health-record
    April 14, 2011 - Commentary Ten strategies to improve management of abnormal test result alerts in the electronic health record. Citation Text: Singh H, Wilson L, Reis B, et al. Ten strategies to improve management of abnormal test result alerts in the electronic health record. J Patient Saf. 2010;6(2)…

  13. Prevalence of burnout among surgical residents and surgeons in Switzerland. | PSNet

    psnet.ahrq.gov/issue/prevalence-burnout-among-surgical-residents-and-surgeons-switzerland
    December 21, 2014 - Study Prevalence of burnout among surgical residents and surgeons in Switzerland. Citation Text: Businger A, Stefenelli U, Guller U. Prevalence of burnout among surgical residents and surgeons in Switzerland. Arch Surg. 2010;145(10):1013-6. doi:10.1001/archsurg.2010.188. Copy Citatio…

  14. Applying lessons from social psychology to transform the culture of error disclosure. | PSNet

    psnet.ahrq.gov/issue/applying-lessons-social-psychology-transform-culture-error-disclosure
    March 20, 2024 - Commentary Applying lessons from social psychology to transform the culture of error disclosure. Citation Text: Han J, LaMarra D, Vapiwala N. Applying lessons from social psychology to transform the culture of error disclosure. Med Educ. 2017;51(10):996-1001. doi:10.1111/medu.13345. Co…

  15. Association between surgeon stress and major surgical complications. | PSNet

    psnet.ahrq.gov/issue/association-between-surgeon-stress-and-major-surgical-complications
    November 29, 2023 - Study Association between surgeon stress and major surgical complications. Citation Text: Awtry J, Skinner S, Polazzi S, et al. Association between surgeon stress and major surgical complications. JAMA Surg. 2025;160(3):332-340. doi:10.1001/jamasurg.2024.6072. Copy Citation Format:…

  16. Clinical features and preventability of delayed diagnosis of pediatric appendicitis. | PSNet

    psnet.ahrq.gov/issue/clinical-features-and-preventability-delayed-diagnosis-pediatric-appendicitis
    September 13, 2023 - Study Clinical features and preventability of delayed diagnosis of pediatric appendicitis. Citation Text: Michelson KA, Reeves SD, Grubenhoff JA, et al. Clinical features and preventability of delayed diagnosis of pediatric appendicitis. JAMA Netw Open. 2021;4(8):e2122248. doi:10.1001/ja…

  17. Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team training. | PSNet

    psnet.ahrq.gov/issue/surgical-programs-veterans-health-administration-maintain-briefing-and-debriefing-following
    October 24, 2018 - Study Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team training. Citation Text: West P, Neily J, Warner L, et al. Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team…

  18. Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program. | PSNet

    psnet.ahrq.gov/issue/improving-perceptions-teamwork-climate-veterans-health-administration-medical-team-training
    December 21, 2014 - Study Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program. Citation Text: Carney BT, West P, Neily J, et al. Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program. Am J…

  19. Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future). | PSNet

    psnet.ahrq.gov/issue/measuring-patient-safety-medicare-patient-safety-monitoring-system-past-present-and-future
    December 18, 2014 - Review Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future). Citation Text: Classen D, Munier W, Verzier N, et al. Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future). J Patient Saf. 2021;17(3)…

  20. 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: …
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