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  1. psnet.ahrq.gov/issue/perfect-storm-averted-flawed-systems-dropped-ball-and-cognitive-biases-delay-critical
    November 30, 2022 - Commentary A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. Citation Text: Roberts TJ, Sellars MC, Sands JM, et al. A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. JCO Oncol…
  2. psnet.ahrq.gov/issue/missed-breast-cancer-effects-subconscious-bias-and-lesion-characteristics
    February 02, 2022 - Commentary Missed breast cancer: effects of subconscious bias and lesion characteristics. Citation Text: Lamb LR, Mohallem Fonseca M, Verma R, et al. Missed breast cancer: effects of subconscious bias and lesion characteristics. RadioGraphics. 2020;40(4):941-960. doi:10.1148/rg.202019009…
  3. psnet.ahrq.gov/issue/integrative-review-patient-safety-studies-care-and-safety-patients-communication-disabilities
    April 10, 2019 - Review An integrative review of patient safety in studies on the care and safety of patients with communication disabilities in hospital. Citation Text: Hemsley B, Georgiou A, Hill S, et al. An integrative review of patient safety in studies on the care and safety of patients with commun…
  4. psnet.ahrq.gov/issue/problem-preventable-deaths
    July 24, 2024 - Commentary The problem with preventable deaths. Citation Text: Hogan H. The problem with preventable deaths. BMJ Qual Saf. 2016;25(5):320-3. doi:10.1136/bmjqs-2015-004983. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…
  5. psnet.ahrq.gov/issue/user-satisfaction-computerized-order-entry-system-and-its-effect-workplace-level-stress
    August 27, 2017 - Study User satisfaction with computerized order entry system and its effect on workplace level of stress. Citation Text: Ghahramani N, Lendel I, Haque R, et al. User satisfaction with computerized order entry system and its effect on workplace level of stress. J Med Syst. 2009;33(3):19…
  6. psnet.ahrq.gov/issue/health-care-huddles-managing-complexity-achieve-high-reliability
    November 17, 2015 - Study Health care huddles: managing complexity to achieve high reliability. Citation Text: Provost SM, Lanham H, Leykum LK, et al. Health care huddles: managing complexity to achieve high reliability. Health Care Manage Rev. 2015;40(1):2-12. doi:10.1097/HMR.0000000000000009. Copy Citat…
  7. psnet.ahrq.gov/issue/multi-professional-patterns-and-methods-communication-during-patient-handoffs
    January 30, 2019 - Study Multi-professional patterns and methods of communication during patient handoffs. Citation Text: Benham-Hutchins MM, Effken JA. Multi-professional patterns and methods of communication during patient handoffs. Int J Med Inform. 2010;79(4):252-67. doi:10.1016/j.ijmedinf.2009.12.00…
  8. psnet.ahrq.gov/issue/effect-systems-intervention-quality-and-safety-patient-handoffs-internal-medicine-residency
    May 08, 2017 - Study Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program. Citation Text: Graham KL, Marcantonio ER, Huang GC, et al. Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicin…
  9. psnet.ahrq.gov/issue/systematic-review-falls-hospital-patients-communication-disability-highlighting-invisible
    April 15, 2016 - Review A systematic review of falls in hospital for patients with communication disability: highlighting an invisible population. Citation Text: Hemsley B, Steel J, Worrall L, et al. A systematic review of falls in hospital for patients with communication disability: Highlighting an invi…
  10. psnet.ahrq.gov/issue/theoretical-framework-and-competency-based-approach-improving-handoffs
    March 28, 2011 - Commentary A theoretical framework and competency-based approach to improving handoffs. Citation Text: Arora VM, Johnson JK, Meltzer DO, et al. A theoretical framework and competency-based approach to improving handoffs. Qual Saf Health Care. 2008;17(1):11-4. doi:10.1136/qshc.2006.0189…
  11. psnet.ahrq.gov/issue/patient-and-physician-experience-interhospital-transfer-qualitative-study
    April 12, 2023 - Study Patient and physician experience with interhospital transfer: a qualitative study. Citation Text: Mueller SK, Shannon E, Dalal A, et al. Patient and Physician Experience with Interhospital Transfer: A Qualitative Study. J Patient Saf. 2021;17(8):e752-e757. doi:10.1097/PTS.000000000…
  12. psnet.ahrq.gov/issue/safe-use-electronic-health-records-and-health-information-technology-systems-trust-verify
    August 02, 2015 - Study Safe use of electronic health records and health information technology systems: trust but verify. Citation Text: Denham CR, Classen D, Swenson SJ, et al. Safe use of electronic health records and health information technology systems: trust but verify. J Patient Saf. 2013;9(4):17…
  13. psnet.ahrq.gov/issue/nature-and-occurrence-registration-errors-emergency-department
    September 28, 2016 - Study The nature and occurrence of registration errors in the emergency department. Citation Text: Hakimzada AF, Green RA, Sayan OR, et al. The nature and occurrence of registration errors in the emergency department. Int J Med Inform. 2007;77(3). doi:10.1016/j.ijmedinf.2007.04.011. …
  14. psnet.ahrq.gov/issue/listening-and-question-asking-behaviors-resident-and-nurse-handoff-conversations-prospective
    June 27, 2018 - Study Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study. Citation Text: Kannampallil TG, Abraham J. Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study.…
  15. psnet.ahrq.gov/issue/drug-formulations-require-potentially-inaccurate-volumes-prepare-doses-infants-and-children
    April 22, 2011 - Study Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children. Citation Text: Uppal N, Yasseen B, Seto W, et al. Drug formulations that require less than 0.1 mL of stock solution to prepare doses for infants and children. CMAJ. 2011;183(4…
  16. psnet.ahrq.gov/issue/management-arterial-lines-and-blood-sampling-intensive-care-threat-patient-safety
    November 12, 2014 - Study Management of arterial lines and blood sampling in intensive care: a threat to patient safety. Citation Text: Leslie RA, Gouldson S, Habib N, et al. Management of arterial lines and blood sampling in intensive care: a threat to patient safety. Anaesthesia. 2013;68(11). doi:10.1111…
  17. psnet.ahrq.gov/issue/psych-mnemonic-help-psychiatric-residents-decrease-patient-handoff-communication-errors
    November 16, 2022 - Study PSYCH: a mnemonic to help psychiatric residents decrease patient handoff communication errors. Citation Text: Mariano MT, Brooks V, DiGiacomo M. PSYCH: A Mnemonic to Help Psychiatric Residents Decrease Patient Handoff Communication Errors. Jt Comm J Qual Patient Saf. 2016;42(7):316…
  18. psnet.ahrq.gov/issue/prospective-memory-icu-effect-visual-cues-task-execution-representative-simulation
    April 24, 2018 - Study Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. Citation Text: Grundgeiger T, Sanderson PM, Orihuela B, et al. Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. Ergo…
  19. psnet.ahrq.gov/issue/evidence-guiding-practice-reported-versus-observed-adherence-contact-precautions-pilot-study
    June 28, 2017 - Study Is evidence guiding practice? Reported versus observed adherence to contact precautions: a pilot study. Citation Text: Jessee MA, Mion LC. Is evidence guiding practice? Reported versus observed adherence to contact precautions: a pilot study. Am J Infect Control. 2013;41(11):965-…
  20. psnet.ahrq.gov/issue/e-prescribing-errors-community-pharmacies-exploring-consequences-and-contributing-factors
    January 07, 2015 - Study E-prescribing errors in community pharmacies: exploring consequences and contributing factors. Citation Text: Odukoya OK, Stone JA, Chui MA. E-prescribing errors in community pharmacies: exploring consequences and contributing factors. Int J Med Inform. 2014;83(6):427-37. doi:10.10…

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