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psnet.ahrq.gov/issue/medication-errors-how-reliable-are-severity-ratings-reported-national-reporting-and-learning
September 09, 2015 - Study
Medication errors: how reliable are the severity ratings reported to the National Reporting and Learning System?
Citation Text:
Williams SD, Ashcroft DM. Medication errors: how reliable are the severity ratings reported to the national reporting and learning system? Int J Qual He…
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psnet.ahrq.gov/issue/improving-governance-patient-safety-emergency-care-systematic-review-interventions
March 06, 2013 - Review
Improving the governance of patient safety in emergency care: a systematic review of interventions.
Citation Text:
Hesselink G, Berben S, Beune T, et al. Improving the governance of patient safety in emergency care: a systematic review of interventions. BMJ Open. 2016;6(1):e009837…
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psnet.ahrq.gov/issue/development-trigger-tool-identify-adverse-events-and-harm-emergency-medical-services
August 07, 2024 - Study
Development of a trigger tool to identify adverse events and harm in emergency medical services.
Citation Text:
Howard IL, Bowen JM, Shaikh LAHA, et al. Development of a trigger tool to identify adverse events and harm in Emergency Medical Services. Emerg Med J. 2017;34(6):391-397.…
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psnet.ahrq.gov/issue/diagnostic-delays-among-covid-19-patients-second-concurrent-diagnosis
March 08, 2023 - Study
Diagnostic delays among COVID-19 patients with a second concurrent diagnosis.
Citation Text:
Freund O, Azolai L, Sror N, et al. Diagnostic delays among COVID‐19 patients with a second concurrent diagnosis. J Hosp Med. 2023;18(4):321-328. doi:10.1002/jhm.13063.
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psnet.ahrq.gov/issue/embracing-errors-simulation-based-training-effect-error-training-retention-and-transfer
May 23, 2013 - Study
Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills.
Citation Text:
Gardner AK, Abdelfattah K, Wiersch J, et al. Embracing Errors in Simulation-Based Training: The Effect of Error Training on Retent…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-neurodevt.pdf
June 02, 2025 - NICU Family Information Packet, Appendix B, Neurodevelopment
Neurodevelopment
Risk Factors for Poor Neurodevelopmental Outcome
■ Developmental progress may be variable for motor and language skills.
■ BPD, even in the absence of overt brain injury, is a risk factor for neurodevelopmental delay.
■ Peri- or intra…
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psnet.ahrq.gov/issue/multidisciplinary-simulation-activity-effectively-prepares-residents-participation-patient
November 30, 2016 - Study
Multidisciplinary simulation activity effectively prepares residents for participation in patient safety activities.
Citation Text:
Weis JJ, Croft CL, Bhoja R, et al. Multidisciplinary simulation activity effectively prepares residents for participation in patient safety activities…
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psnet.ahrq.gov/issue/medication-error-prevention-survey-five-years-results
March 26, 2015 - Study
A medication error prevention survey: five years of results.
Citation Text:
Cusano FL, Chambers C, Summach L. A medication error prevention survey: five years of results. J Oncol Pharm Pract. 2009;15(2):87-93. doi:10.1177/1078155208099284.
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psnet.ahrq.gov/issue/relationship-staff-information-sharing-and-advice-networks-patient-safety-outcomes
June 22, 2011 - Study
Relationship of staff information sharing and advice networks to patient safety outcomes.
Citation Text:
Brewer BB, Carley KM, Benham-Hutchins MM, et al. Relationship of Staff Information Sharing and Advice Networks to Patient Safety Outcomes. J Nurs Adm. 2018;48(9):437-444. doi:10…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses2.html
August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department
The Theory of Distributed Cognition
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Table of Contents
Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department
Introduction
The Theory of Dis…
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psnet.ahrq.gov/issue/using-inpatient-hospital-discharge-data-monitor-patient-safety-events
March 02, 2011 - Study
Using inpatient hospital discharge data to monitor patient safety events.
Citation Text:
Taylor JA, Pandian RS, Mao L, et al. Using inpatient hospital discharge data to monitor patient safety events. J Healthc Risk Manag. 2013;32(4):26-33. doi:10.1002/jhrm.21107.
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psnet.ahrq.gov/issue/failures-care-coordination-and-reviewing-patients-death-va-salt-lake-city-healthcare-system
April 19, 2023 - Book/Report
Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah.
Citation Text:
Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. Washington, DC: Department of Vet…
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psnet.ahrq.gov/issue/role-pediatric-nurses-during-preventable-adverse-event-disclosure-scoping-review
October 19, 2022 - Review
The role of pediatric nurses during preventable adverse event disclosure: a scoping review.
Citation Text:
Sexton JR, Kelly-Weeder S. The role of pediatric nurses during preventable adverse event disclosure: a scoping review. J Patient Saf. 2024;20(6):381-387. doi:10.1097/pts.0000…
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psnet.ahrq.gov/issue/are-pathologists-self-aware-their-diagnostic-accuracy-metacognition-and-diagnostic-process
May 18, 2022 - Study
Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology.
Citation Text:
Clayton DA, Eguchi MM, Kerr KF, et al. Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology. Me…
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psnet.ahrq.gov/issue/perspective-malpractice-academic-medical-center-frequently-overlooked-aspect-professionalism
April 03, 2024 - Commentary
Perspective: malpractice in an academic medical center: a frequently overlooked aspect of professionalism education.
Citation Text:
Hochberg MS, Seib CD, Berman RS, et al. Perspective: Malpractice in an academic medical center: a frequently overlooked aspect of professionali…
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psnet.ahrq.gov/issue/incidence-adverse-events-among-home-care-patients
December 04, 2015 - Study
The incidence of adverse events among home care patients.
Citation Text:
Sears NA, Baker R, Barnsley J, et al. The incidence of adverse events among home care patients. Int J Qual Health Care. 2013;25(1):16-28. doi:10.1093/intqhc/mzs075.
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psnet.ahrq.gov/issue/rapidly-increasing-rapid-response-team-activation-rates
February 18, 2015 - Study
Rapidly increasing rapid response team activation rates.
Citation Text:
Braaten JS, deGunst G, Bilys K. Rapidly Increasing Rapid Response Team Activation Rates. Jt Comm J Qual Patient Saf. 2015;41(9):421-427.
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psnet.ahrq.gov/issue/simulation-executive-suite-lessons-learned-building-patient-safety-leadership
July 21, 2017 - Study
Simulation in the executive suite: lessons learned for building patient safety leadership.
Citation Text:
Rosen MA, Goeschel CA, Che X-X, et al. Simulation in the Executive Suite: Lessons Learned for Building Patient Safety Leadership. Simul Healthc. 2015;10(6):372-377.
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psnet.ahrq.gov/issue/how-effective-teamwork-really-relationship-between-teamwork-and-performance-healthcare-teams
February 14, 2017 - Review
Classic
How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis.
Citation Text:
Schmutz JB, Meier LL, Manser T. How effective is teamwork really? The relationship betwe…
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psnet.ahrq.gov/issue/organizational-ambidexterity-and-hybrid-middle-manager-case-patient-safety-uk-hospitals
January 29, 2014 - Study
Organizational ambidexterity and the hybrid middle manager: the case of patient safety in UK hospitals.
Citation Text:
Burgess N, Strauss K, Currie G, et al. Organizational Ambidexterity and the Hybrid Middle Manager: The Case of Patient Safety in UK Hospitals. Hum Resour Manage. 2…