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  1. Characteristics of pediatric chemotherapy medication errors in a national error reporting database. | PSNet

    psnet.ahrq.gov/issue/characteristics-pediatric-chemotherapy-medication-errors-national-error-reporting-database
    September 21, 2008 - Study Characteristics of pediatric chemotherapy medication errors in a national error reporting database. Citation Text: Rinke ML, Shore AD, Morlock L, et al. Characteristics of pediatric chemotherapy medication errors in a national error reporting database. Cancer. 2007;110(1):186-95.…

  2. Unplanned return to theater: a quality of care and risk management index? | PSNet

    psnet.ahrq.gov/issue/unplanned-return-theater-quality-care-and-risk-management-index
    August 20, 2018 - Study Unplanned return to theater: a quality of care and risk management index? Citation Text: Pujol N, Merrer J, Lemaire B, et al. Unplanned return to theater: A quality of care and risk management index? Orthop Traumatol Surg Res. 2015;101(4):399-403. doi:10.1016/j.otsr.2015.03.013. …

  3. NICU Family Information Packet, Appendix B, Neurodevelopment (pdf file)

    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…

  4. Patient perspectives on delays in diagnosis and treatment of cancer: a qualitative analysis of free-text data. | PSNet

    psnet.ahrq.gov/issue/patient-perspectives-delays-diagnosis-and-treatment-cancer-qualitative-analysis-free-text
    March 08, 2023 - Study Patient perspectives on delays in diagnosis and treatment of cancer: a qualitative analysis of free-text data. Citation Text: Parsonage RK, Hiscock J, Law R-J, et al. Patient perspectives on delays in diagnosis and treatment of cancer: a qualitative analysis of free-text data. Br J…

  5. Multidisciplinary simulation activity effectively prepares residents for participation in patient safety activities. | PSNet

    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…

  6. A medication error prevention survey: five years of results. | PSNet

    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. Copy Citation Format: DOI …

  7. Relationship of staff information sharing and advice networks to patient safety outcomes. | PSNet

    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…

  8. The Theory of Distributed Cognition | Agency for Healthcare Research and Quality

    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 Previous Page Next Page Table of Contents Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Introduction The Theory of Dis…

  9. Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. | PSNet

    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…

  10. Perspective: malpractice in an academic medical center: a frequently overlooked aspect of professionalism education. | PSNet

    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…

  11. The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project | PSNet

    psnet.ahrq.gov/issue/impact-post-fall-huddles-repeat-fall-rates-and-perceptions-safety-culture-quasi-experimental
    December 30, 2014 - Journal Article The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project Citation Text: Jones KJ, Crowe J, Allen JA, et al. The impact of post-fall huddles on repeat fall rates and pe…

  12. Errors in laboratory medicine: practical lessons to improve patient safety. | PSNet

    psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patient-safety
    February 14, 2024 - Commentary Classic Errors in laboratory medicine: practical lessons to improve patient safety. Citation Text: Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab Med. 2005;129(10):1252-1261. Copy Citation …

  13. Crossing the communication chasm: challenges and opportunities in transitions of care from the hospital to the primary care clinic. | PSNet

    psnet.ahrq.gov/issue/crossing-communication-chasm-challenges-and-opportunities-transitions-care-hospital-primary
    October 23, 2024 - Study Crossing the communication chasm: challenges and opportunities in transitions of care from the hospital to the primary care clinic. Citation Text: Rattray NA, Sico JJ, Cox LAM, et al. Crossing the Communication Chasm: Challenges and Opportunities in Transitions of Care from the Hos…

  14. Retained guidewires in the Veterans Health Administration: getting to the root of the problem. | PSNet

    psnet.ahrq.gov/issue/retained-guidewires-veterans-health-administration-getting-root-problem
    March 13, 2013 - Study Retained guidewires in the Veterans Health Administration: getting to the root of the problem. Citation Text: Cherara L, Sculli GL, Paull DE, et al. Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem. J Patient Saf. 2021;17(8):e991-e928. d…

  15. Exploring the causes of COPD misdiagnosis in primary care: a mixed methods study. | PSNet

    psnet.ahrq.gov/issue/exploring-causes-copd-misdiagnosis-primary-care-mixed-methods-study
    September 23, 2020 - Study Exploring the causes of COPD misdiagnosis in primary care: a mixed methods study. Citation Text: Patel K, Smith DJ, Huntley CC, et al. Exploring the causes of COPD misdiagnosis in primary care: a mixed methods study. PLoS ONE. 2024;19(3):e0298432. doi:10.1371/journal.pone.0298432. …

  16. Rapidly increasing rapid response team activation rates. | PSNet

    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. Copy Citation Format: Google Scholar PubMed BibTeX EndNote …

  17. Simulation in the executive suite: lessons learned for building patient safety leadership. | PSNet

    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. Copy Cita…

  18. Patient safety begins with proper planning: a quantitative method to improve hospital design. | PSNet

    psnet.ahrq.gov/issue/patient-safety-begins-proper-planning-quantitative-method-improve-hospital-design
    July 19, 2023 - Study Patient safety begins with proper planning: a quantitative method to improve hospital design. Citation Text: Birnbach DJ, Nevo I, Scheinman SR, et al. Patient safety begins with proper planning: a quantitative method to improve hospital design. Qual Saf Health Care. 2010;19(5):46…

  19. A systematic review of simulation for multidisciplinary team training in operating rooms. | PSNet

    psnet.ahrq.gov/issue/systematic-review-simulation-multidisciplinary-team-training-operating-rooms
    November 17, 2014 - Review A systematic review of simulation for multidisciplinary team training in operating rooms. Citation Text: Cumin D, Boyd MJ, Webster CS, et al. A systematic review of simulation for multidisciplinary team training in operating rooms. Simul Healthc. 2013;8(3):171-179. doi:10.1097/S…

  20. How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis. | PSNet

    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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