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  1. Sensemaking of patient safety risks and hazards. | PSNet

    psnet.ahrq.gov/issue/sensemaking-patient-safety-risks-and-hazards
    March 03, 2011 - Commentary Sensemaking of patient safety risks and hazards. Citation Text: Battles J, Dixon NM, Borotkanics RJ, et al. Sensemaking of patient safety risks and hazards. Health Serv Res. 2006;41(4 Pt 2):1555-1575. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X…

  2. Re-examining high reliability: actively organising for safety. | PSNet

    psnet.ahrq.gov/issue/re-examining-high-reliability-actively-organising-safety
    October 13, 2018 - Commentary Re-examining high reliability: actively organising for safety. Citation Text: Sutcliffe K, Paine LA, Pronovost P. Re-examining high reliability: actively organising for safety. BMJ Qual Saf. 2017;26(3):248-251. doi:10.1136/bmjqs-2015-004698. Copy Citation Format: …

  3. Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. | PSNet

    psnet.ahrq.gov/issue/mind-overlap-how-system-problems-contribute-cognitive-failure-and-diagnostic-errors
    August 14, 2019 - Study Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. Citation Text: Gupta A, Harrod M, Quinn M, et al. Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. Diagnosis (Berl). 2018;5(3):151-156. doi:10.15…

  4. Effect of a pharmacist-led educational intervention on inappropriate medication prescriptions in older adults: the D-PRESCRIBE randomized clinical trial. | PSNet

    psnet.ahrq.gov/issue/effect-pharmacist-led-educational-intervention-inappropriate-medication-prescriptions-older
    February 14, 2017 - Study Classic Effect of a pharmacist-led educational intervention on inappropriate medication prescriptions in older adults: the D-PRESCRIBE randomized clinical trial. Citation Text: Martin P, Tamblyn R, Benedetti A, et al. Effect of a Pharmacist-Led Educational…

  5. Using nurses and office staff to report prescribing errors in primary care. | PSNet

    psnet.ahrq.gov/issue/using-nurses-and-office-staff-report-prescribing-errors-primary-care
    May 04, 2010 - Study Using nurses and office staff to report prescribing errors in primary care. Citation Text: Kennedy AG, Littenberg B, Senders JW. Using nurses and office staff to report prescribing errors in primary care. Int J Qual Health Care. 2008;20(4):238-45. doi:10.1093/intqhc/mzn015. Cop…

  6. Introduction of checklists at daily progress notes improves patient care among the gynecological oncology service. | PSNet

    psnet.ahrq.gov/issue/introduction-checklists-daily-progress-notes-improves-patient-care-among-gynecological
    October 19, 2022 - Study Introduction of checklists at daily progress notes improves patient care among the gynecological oncology service. Citation Text: Diaz-Montes TP, Cobb L, Ibeanu OA, et al. Introduction of checklists at daily progress notes improves patient care among the gynecological oncology se…

  7. Women's safety alerts in maternity care: is speaking up enough? | PSNet

    psnet.ahrq.gov/issue/womens-safety-alerts-maternity-care-speaking-enough
    July 08, 2015 - Study Women's safety alerts in maternity care: is speaking up enough? Citation Text: Rance S, McCourt C, Rayment J, et al. Women's safety alerts in maternity care: is speaking up enough? BMJ Qual Saf. 2013;22(4):348-55. doi:10.1136/bmjqs-2012-001295. Copy Citation Format: …

  8. Mapping changes in surgical mortality over 9 years by peer review audit. | PSNet

    psnet.ahrq.gov/issue/mapping-changes-surgical-mortality-over-9-years-peer-review-audit
    March 04, 2011 - Study Mapping changes in surgical mortality over 9 years by peer review audit. Citation Text: Thompson A, Ashraf Z, Burton H, et al. Mapping changes in surgical mortality over 9 years by peer review audit. Br J Surg. 2005;92(11):1449-52. Copy Citation Format: Google Schol…

  9. The HOSPITAL score predicts potentially preventable 30-day readmissions in conditions targeted by the Hospital Readmissions Reduction Program. | PSNet

    psnet.ahrq.gov/issue/hospital-score-predicts-potentially-preventable-30-day-readmissions-conditions-targeted
    May 08, 2017 - Study The HOSPITAL score predicts potentially preventable 30-day readmissions in conditions targeted by the Hospital Readmissions Reduction Program. Citation Text: Burke RE, Schnipper JL, Williams M, et al. The HOSPITAL Score Predicts Potentially Preventable 30-Day Readmissions in Condit…

  10. Transfers of patient care between house staff on internal medicine wards: a national survey. | PSNet

    psnet.ahrq.gov/issue/transfers-patient-care-between-house-staff-internal-medicine-wards-national-survey
    August 15, 2018 - Study Transfers of patient care between house staff on internal medicine wards: a national survey. Citation Text: Horwitz LI, Krumholz HM, Green M, et al. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166(11):1173-7. …

  11. A study of the frequency and rationale for overriding allergy warnings in a computerized prescriber order entry system. | PSNet

    psnet.ahrq.gov/issue/study-frequency-and-rationale-overriding-allergy-warnings-computerized-prescriber-order-entry
    February 15, 2011 - Study A study of the frequency and rationale for overriding allergy warnings in a computerized prescriber order entry system. Citation Text: Swiderski SM, Pedersen CA, Schneider PJ, et al. A Study of the Frequency and Rationale for Overriding Allergy Warnings in a Computerized Prescrib…

  12. Online medication error graphic reports: a pilot in North Carolina nursing homes. | PSNet

    psnet.ahrq.gov/issue/online-medication-error-graphic-reports-pilot-north-carolina-nursing-homes
    March 24, 2011 - Study Online medication error graphic reports: a pilot in North Carolina nursing homes. Citation Text: Greene SB, Williams CE, Pierson S, et al. Online medication error graphic reports: a pilot in North Carolina nursing homes. J Patient Saf. 2011;7(2):92-8. doi:10.1097/PTS.0b013e31821b4…

  13. Handover after pediatric heart surgery: a simple tool improves information exchange. | PSNet

    psnet.ahrq.gov/issue/handover-after-pediatric-heart-surgery-simple-tool-improves-information-exchange
    July 03, 2016 - Study Handover after pediatric heart surgery: a simple tool improves information exchange. Citation Text: Zavalkoff SR, Razack SI, Lavoie J, et al. Handover after pediatric heart surgery: a simple tool improves information exchange. Pediatr Crit Care Med. 2011;12(3):309-13. doi:10.1097/…

  14. Development of patient safety measures to identify inappropriate diagnosis of common infections. | PSNet

    psnet.ahrq.gov/issue/development-patient-safety-measures-identify-inappropriate-diagnosis-common-infections
    April 10, 2024 - Study Development of patient safety measures to identify inappropriate diagnosis of common infections. Citation Text: White AT, Vaughn VM, Petty LA, et al. Development of patient safety measures to identify inappropriate diagnosis of common infections. Clin Infect Dis. 2024;78(6):1403-14…

  15. Data-driven implementation of alarm reduction interventions in a cardiovascular surgical ICU. | PSNet

    psnet.ahrq.gov/issue/data-driven-implementation-alarm-reduction-interventions-cardiovascular-surgical-icu
    August 17, 2017 - Study Data-driven implementation of alarm reduction interventions in a cardiovascular surgical ICU. Citation Text: Allan SH, Doyle PA, Sapirstein A, et al. Data-Driven Implementation of Alarm Reduction Interventions in a Cardiovascular Surgical ICU. Jt Comm J Qual Patient Saf. 2017;43(2)…

  16. Medication safety program reduces adverse drug events in a community hospital. | PSNet

    psnet.ahrq.gov/issue/medication-safety-program-reduces-adverse-drug-events-community-hospital
    April 24, 2018 - Study Medication safety program reduces adverse drug events in a community hospital. Citation Text: Cohen MM, Kimmel NL, Benage MK, et al. Medication safety program reduces adverse drug events in a community hospital. Qual Saf Health Care. 2005;14(3):169-74. Copy Citation Format:…

  17. Infection control assessment of ambulatory surgical centers. | PSNet

    psnet.ahrq.gov/issue/infection-control-assessment-ambulatory-surgical-centers
    October 19, 2012 - Study Infection control assessment of ambulatory surgical centers. Citation Text: Schaefer MK, Jhung M, Dahl M, et al. Infection control assessment of ambulatory surgical centers. JAMA. 2010;303(22):2273-9. doi:10.1001/jama.2010.744. Copy Citation Format: DOI Google Schol…

  18. Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study. | PSNet

    psnet.ahrq.gov/issue/prevalence-errors-anaphylaxis-kids-peak-multicenter-simulation-based-study
    June 15, 2022 - Study Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study. Citation Text: Maa T, Scherzer DJ, Harwayne-Gidansky I, et al. Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study. J Allergy Clin Immunol Pract. 2020;8(4)…

  19. Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions. | PSNet

    psnet.ahrq.gov/issue/incidence-potentially-avoidable-urgent-readmissions-and-their-relation-all-cause-urgent
    April 22, 2011 - Study Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions. Citation Text: van Walraven C, Jennings A, Taljaard M, et al. Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions. Ca…

  20. Patient whiteboards as a communication tool in the hospital setting: A survey of practices and recommendations. | PSNet

    psnet.ahrq.gov/issue/patient-whiteboards-communication-tool-hospital-setting-survey-practices-and-recommendations
    February 18, 2011 - Study Patient whiteboards as a communication tool in the hospital setting: A survey of practices and recommendations. Citation Text: Sehgal NL, Green A, Vidyarthi A, et al. Patient whiteboards as a communication tool in the hospital setting: a survey of practices and recommendations. J …
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