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  1. Medication orders with future start dates: how far away is too far? | PSNet

    psnet.ahrq.gov/issue/medication-orders-future-start-dates-how-far-away-too-far
    March 15, 2022 - Newspaper/Magazine Article Medication orders with future start dates: how far away is too far? Citation Text: Medication orders with future start dates: how far away is too far? ISMP Medication Safety Alert! Acute care edition. July 14, 2022:27(14):1-4. Copy Citation Sa…

  2. Reevaluation of diagnosis in adults with physician-diagnosed asthma. | PSNet

    psnet.ahrq.gov/issue/reevaluation-diagnosis-adults-physician-diagnosed-asthma
    March 15, 2017 - Study Reevaluation of diagnosis in adults with physician-diagnosed asthma. Citation Text: Aaron SD, Vandemheen KL, FitzGerald M, et al. Reevaluation of Diagnosis in Adults With Physician-Diagnosed Asthma. JAMA. 2017;317(3):269-279. doi:10.1001/jama.2016.19627. Copy Citation Format:…

  3. Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation. | PSNet

    psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-proactive-identification-communication-and-handoff
    August 04, 2021 - Study Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation. Citation Text: Steinberger DM, Douglas S, Kirschbaum MS. Use of failure mode and effects analysis for proactive identification of…

  4. Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. | PSNet

    psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone-overdose
    June 03, 2020 - Newspaper/Magazine Article Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. Citation Text: Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. ISMP Medication Safety Alert! Acute care edition. May 7…

  5. Adaptive regulation or governmentality: patient safety and the changing regulation of medicine. | PSNet

    psnet.ahrq.gov/issue/adaptive-regulation-or-governmentality-patient-safety-and-changing-regulation-medicine
    December 09, 2020 - Commentary Adaptive regulation or governmentality: patient safety and the changing regulation of medicine. Citation Text: Waring J. Adaptive regulation or governmentality: patient safety and the changing regulation of medicine. Sociol Health Illn. 2007;29(2):163-79. Copy Citation …

  6. Engineering a foundation for partnership to improve medication safety during care transitions. | PSNet

    psnet.ahrq.gov/issue/engineering-foundation-partnership-improve-medication-safety-during-care-transitions
    July 20, 2022 - Commentary Engineering a foundation for partnership to improve medication safety during care transitions. Citation Text: Xiao Y, Abebe E, Gurses AP. Engineering a Foundation for Partnership to Improve Medication Safety during Care Transitions. J Patient Saf Risk Manag. 2019;24(1):30-36. …

  7. HCUP Statistical Brief #312. Trends in Severe Maternal Morbidity Complications by Patient Characteristics, 2016-2021. | PSNet

    psnet.ahrq.gov/issue/hcup-statistical-brief-313-trends-severe-maternal-morbidity-complications-patient
    December 16, 2009 - Book/Report HCUP Statistical Brief #312. Trends in Severe Maternal Morbidity Complications by Patient Characteristics, 2016-2021. Citation Text: Reid LD. Hcup Statistical Brief #313. Trends In Severe Maternal Morbidity Complications By Patient Characteristics, 2016-2021. Rockville, MD: A…

  8. The Impact of Complications on Surgeons. | PSNet

    psnet.ahrq.gov/issue/impact-complications-surgeons
    November 16, 2022 - Special or Theme Issue The Impact of Complications on Surgeons. Citation Text: The Impact of Complications on Surgeons. Modi PK, Singer EA, eds. Urol Oncol. 2024;42(10):295-320. doi:10.1016/j.urolonc.2024.05.016. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 X…

  9. Barriers and facilitators to nursing handoffs: recommendations for redesign. | PSNet

    psnet.ahrq.gov/issue/barriers-and-facilitators-nursing-handoffs-recommendations-redesign
    January 22, 2016 - Study Barriers and facilitators to nursing handoffs: recommendations for redesign. Citation Text: Welsh CA, Flanagan ME, Ebright PR. Barriers and facilitators to nursing handoffs: Recommendations for redesign. Nurs Outlook. 2010;58(3):148-154. doi:10.1016/j.outlook.2009.10.005. Copy …

  10. Exploring the barriers to learning from crisis: organizational learning and crisis. | PSNet

    psnet.ahrq.gov/issue/exploring-barriers-learning-crisis-organizational-learning-and-crisis
    January 08, 2025 - Review Exploring the barriers to learning from crisis: organizational learning and crisis. Citation Text: Smith D, Elliott D. Exploring the Barriers to Learning from Crisis. Manag Learn. 2007;38(5):519-538. doi:10.1177/1350507607083205. Copy Citation Format: DOI Google Sc…

  11. Using simulation to teach patient safety behaviors in undergraduate nursing education. | PSNet

    psnet.ahrq.gov/issue/using-simulation-teach-patient-safety-behaviors-undergraduate-nursing-education
    March 23, 2011 - Study Using simulation to teach patient safety behaviors in undergraduate nursing education. Citation Text: Gantt LT, Webb-Corbett R. Using simulation to teach patient safety behaviors in undergraduate nursing education. J Nurs Educ. 2010;49(1):48-51. doi:10.3928/01484834-20090918-10. …

  12. FDA’s promised guidance on pulse oximeters unlikely to end decades of racial bias. | PSNet

    psnet.ahrq.gov/issue/fdas-promised-guidance-pulse-oximeters-unlikely-end-decades-racial-bias
    November 06, 2024 - Newspaper/Magazine Article FDA’s promised guidance on pulse oximeters unlikely to end decades of racial bias. Citation Text: Allen A. FDA’s promised guidance on pulse oximeters unlikely to end decades of racial bias. KFF Health News. October 07, 2024; Copy Citation Format: …

  13. Can we import improvements from industry to healthcare? | PSNet

    psnet.ahrq.gov/issue/can-we-import-improvements-industry-healthcare
    October 30, 2010 - Commentary Can we import improvements from industry to healthcare? Citation Text: Macrae C, Stewart K. Can we import improvements from industry to healthcare? BMJ. 2019;364:l1039. doi:10.1136/bmj.l1039. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML E…

  14. Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. | PSNet

    psnet.ahrq.gov/issue/human-cognition-and-dynamics-failure-rescue-lewis-blackman-case
    April 24, 2018 - Commentary Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. Citation Text: Acquaviva K, Haskell H, Johnson J. Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. J Prof Nurs. 2013;29(2):95-101. doi:10.1016/j.profnurs.2012.12.009.…

  15. What is the effectiveness of reporting systems in promoting learning in healthcare? | PSNet

    psnet.ahrq.gov/issue/what-effectiveness-reporting-systems-promoting-learning-healthcare
    September 23, 2020 - Review What is the effectiveness of reporting systems in promoting learning in healthcare? Citation Text: Sehgal A. What is the effectiveness of reporting systems in promoting learning in healthcare? Br J Hosp Med (Lond). 2024;85(4):1-9. doi:10.12968/hmed.2023.0444. Copy Citation F…

  16. Compensation of chief executive officers at nonprofit US hospitals. | PSNet

    psnet.ahrq.gov/issue/compensation-chief-executive-officers-nonprofit-us-hospitals
    December 18, 2018 - Study Compensation of chief executive officers at nonprofit US hospitals. Citation Text: Joynt KE, Le ST, Orav J, et al. Compensation of chief executive officers at nonprofit US hospitals. JAMA Intern Med. 2014;174(1):61-7. doi:10.1001/jamainternmed.2013.11537. Copy Citation Format…

  17. Barcode medication administration work-arounds: a systematic review and implications for nurse executives. | PSNet

    psnet.ahrq.gov/issue/barcode-medication-administration-work-arounds-systematic-review-and-implications-nurse
    January 10, 2017 - Review Barcode medication administration work-arounds: a systematic review and implications for nurse executives. Citation Text: Voshall B, Piscotty R, Lawrence J, et al. Barcode medication administration work-arounds: a systematic review and implications for nurse executives. J Nurs A…

  18. Why even good physicians do not wash their hands. | PSNet

    psnet.ahrq.gov/issue/why-even-good-physicians-do-not-wash-their-hands
    September 21, 2022 - Commentary Why even good physicians do not wash their hands. Citation Text: Redelmeier DA, Shafir E. Why even good physicians do not wash their hands. BMJ Qual Saf. 2015;24(12):744-7. doi:10.1136/bmjqs-2015-004319. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndN…

  19. Inattentional blindness in medicine. | PSNet

    psnet.ahrq.gov/issue/inattentional-blindness-medicine
    March 31, 2021 - Review Inattentional blindness in medicine. Citation Text: Hults CM, Ding Y, Xie GG, et al. Inattentional blindness in medicine. Cogn Res Princ Implic. 2024;9(1):18. doi:10.1186/s41235-024-00537-x. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

  20. Recommendations to ensure safety of AI in real-world clinical care. | PSNet

    psnet.ahrq.gov/issue/recommendations-ensure-safety-ai-real-world-clinical-care
    December 06, 2023 - Commentary Recommendations to ensure safety of AI in real-world clinical care. Citation Text: Sittig DF, Singh H. Recommendations to ensure safety of AI in real-world clinical care. JAMA. 2025;333(6):457-458. doi:10.1001/jama.2024.24598. Copy Citation Format: DOI Google Sch…
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