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  1. Communicating medication changes to community pharmacy post-discharge: the good, the bad, and the improvements. | PSNet

    psnet.ahrq.gov/issue/communicating-medication-changes-community-pharmacy-post-discharge-good-bad-and-improvements
    June 11, 2014 - Study Communicating medication changes to community pharmacy post-discharge: the good, the bad, and the improvements. Citation Text: Urban R, Paloumpi E, Rana N, et al. Communicating medication changes to community pharmacy post-discharge: the good, the bad, and the improvements. Int J…

  2. Building cultures of high reliability: lessons from the high reliability organization paradigm. | PSNet

    psnet.ahrq.gov/issue/building-cultures-high-reliability-lessons-high-reliability-organization-paradigm
    September 05, 2018 - Review Building cultures of high reliability: lessons from the high reliability organization paradigm. Citation Text: Sutcliffe KM. Building cultures of high reliability: lessons from the high reliability organization paradigm. Anesthesiol Clin. 2023;41(4):707-717. doi:10.1016/j.anclin.2…

  3. Effects of work hour reduction on residents' lives: a systematic review. | PSNet

    psnet.ahrq.gov/issue/effects-work-hour-reduction-residents-lives-systematic-review
    March 02, 2011 - Review Effects of work hour reduction on residents' lives: a systematic review. Citation Text: Fletcher KE, Underwood W, Davis SQ, et al. Effects of Work Hour Reduction on Residents’ Lives. JAMA. 2005;294(9):1088. doi:10.1001/jama.294.9.1088. Copy Citation Format: DOI Goo…

  4. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors. | PSNet

    psnet.ahrq.gov/issue/patient-experience-source-understanding-origins-impact-and-remediation-diagnostic-errors
    August 16, 2023 - Book/Report Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors. Citation Text: Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors. Schlesinger M, Grob R, Gleason K, et al. Rock…

  5. An examination of factors that predict the perioperative culture of safety. | PSNet

    psnet.ahrq.gov/issue/examination-factors-predict-perioperative-culture-safety
    May 12, 2021 - Study An examination of factors that predict the perioperative culture of safety. Citation Text: Wright MI, Polivka B, Abusalem S. An examination of factors that predict the perioperative culture of safety. AORN J. 2021;113(5):465-475. doi:10.1002/aorn.13373. Copy Citation Format: …

  6. Rapid response systems as a patient safety strategy: a systematic review. | PSNet

    psnet.ahrq.gov/issue/rapid-response-systems-patient-safety-strategy-systematic-review
    March 20, 2013 - Review Rapid response systems as a patient safety strategy: a systematic review. Citation Text: Winters BD, Weaver SJ, Pfoh ER, et al. Rapid-response systems as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):417-25. doi:10.7326/0003-4819-158-5-201303051…

  7. Prevent errors during emergency use of hypertonic sodium chloride solutions. | PSNet

    psnet.ahrq.gov/issue/prevent-errors-during-emergency-use-hypertonic-sodium-chloride-solutions
    March 10, 2021 - Newspaper/Magazine Article Prevent errors during emergency use of hypertonic sodium chloride solutions. Citation Text: Prevent errors during emergency use of hypertonic sodium chloride solutions. ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4. Copy Citat…

  8. Human factors engineering: its place and potential in OR safety. | PSNet

    psnet.ahrq.gov/issue/human-factors-engineering-its-place-and-potential-or-safety
    May 24, 2017 - Commentary Human factors engineering: its place and potential in OR safety. Citation Text: Criscitelli T. Human factors engineering: its place and potential in OR safety. AORN J. 2015;101(5):571-3. doi:10.1016/j.aorn.2015.02.013. Copy Citation Format: DOI Google Scholar Pub…

  9. Missed nursing care: a concept analysis. | PSNet

    psnet.ahrq.gov/issue/missed-nursing-care-concept-analysis
    January 19, 2022 - Commentary Missed nursing care: a concept analysis. Citation Text: Kalisch BJ, Landstrom GL, Hinshaw AS. Missed nursing care: a concept analysis. J Adv Nurs. 2009;65(7):1509-17. doi:10.1111/j.1365-2648.2009.05027.x. Copy Citation Format: DOI Google Scholar PubMed BibTeX End…

  10. Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief. | PSNet

    psnet.ahrq.gov/issue/pain-management-and-prescription-opioid-related-harms-exploring-state-evidence-proceedings
    July 05, 2008 - Meeting/Conference Proceedings Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief. Citation Text: Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Works…

  11. Barriers to self-reporting patient safety incidents by paramedics: a mixed methods study. | PSNet

    psnet.ahrq.gov/issue/barriers-self-reporting-patient-safety-incidents-paramedics-mixed-methods-study
    November 16, 2022 - Study Barriers to self-reporting patient safety incidents by paramedics: a mixed methods study. Citation Text: Sinclair JE, Austin MA, Bourque C, et al. Barriers to Self-Reporting Patient Safety Incidents by Paramedics: A Mixed Methods Study. Prehosp Emerg Care. 2018;22(6):762-772. doi:1…

  12. Variation in surgical time-out and site marking within pediatric otolaryngology. | PSNet

    psnet.ahrq.gov/issue/variation-surgical-time-out-and-site-marking-within-pediatric-otolaryngology
    October 27, 2010 - Study Variation in surgical time-out and site marking within pediatric otolaryngology. Citation Text: Shah RK, Arjmand E, Roberson DW, et al. Variation in surgical time-out and site marking within pediatric otolaryngology. Arch Otolaryngol Head Neck Surg. 2011;137(1):69-73. doi:10.1001/a…

  13. "It is the left eye, right?" | PSNet

    psnet.ahrq.gov/issue/it-left-eye-right
    September 06, 2023 - Study "It is the left eye, right?" Citation Text: Pikkel D, Sharabi-Nov A, Pikkel J. "It is the left eye, right?". Risk Manag Healthc Policy. 2014;7:77-80. doi:10.2147/RMHP.S60728. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

  14. Clinician factors associated with delayed diagnosis of appendicitis. | PSNet

    psnet.ahrq.gov/issue/clinician-factors-associated-delayed-diagnosis-appendicitis
    October 26, 2022 - Study Clinician factors associated with delayed diagnosis of appendicitis. Citation Text: Michelson KA, McGarghan FLE, Patterson EE, et al. Clinician factors associated with delayed diagnosis of appendicitis. Diagnosis (Berl). 2023;10(2):183-186. doi:10.1515/dx-2022-0119. Copy Citation…

  15. Influence of house-staff experience on teaching-hospital mortality: the "July Phenomenon" revisited. | PSNet

    psnet.ahrq.gov/issue/influence-house-staff-experience-teaching-hospital-mortality-july-phenomenon-revisited
    March 04, 2015 - Study Influence of house-staff experience on teaching-hospital mortality: the "July Phenomenon" revisited. Citation Text: van Walraven C, Jennings A, Wong J, et al. Influence of house-staff experience on teaching-hospital mortality: the "July phenomenon" revisited. J Hosp Med. 2011;6(7…

  16. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. | PSNet

    psnet.ahrq.gov/issue/advancing-science-measurement-diagnostic-errors-healthcare-safer-dx-framework
    December 06, 2023 - Commentary Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. Citation Text: Singh H, Sittig DF. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. BMJ Qual Saf. 2015;24(2):103-110. doi:10.1136/bm…

  17. How surgical trainees handle catastrophic errors: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/how-surgical-trainees-handle-catastrophic-errors-qualitative-study
    March 19, 2019 - Study How surgical trainees handle catastrophic errors: a qualitative study. Citation Text: Balogun JA, Bramall AN, Bernstein M. How Surgical Trainees Handle Catastrophic Errors: A Qualitative Study. J Surg Educ. 2015;72(6):1179-84. doi:10.1016/j.jsurg.2015.05.003. Copy Citation Fo…

  18. Measurement of ambulatory medication errors in children: a scoping review. | PSNet

    psnet.ahrq.gov/issue/measurement-ambulatory-medication-errors-children-scoping-review
    February 07, 2024 - Review Measurement of ambulatory medication errors in children: a scoping review. Citation Text: Rickey L, Auger K, Britto MT, et al. Measurement of ambulatory medication errors in children: a scoping review. Pediatrics. 2023;152(6):e2023061281. doi:10.1542/peds.2023-061281. Copy Citat…

  19. Communication failures: an insidious contributor to medical mishaps. | PSNet

    psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps
    February 24, 2011 - Study Classic Communication failures: an insidious contributor to medical mishaps. Citation Text: Sutcliffe K, Lewton E, Rosenthal M. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79(2):186-194. Copy Citation Format:…

  20. Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surgical patients. | PSNet

    psnet.ahrq.gov/issue/beyond-our-walls-impact-patient-and-provider-coordination-across-continuum-outcomes-surgical
    March 24, 2021 - Study Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surgical patients. Citation Text: Weinberg DB, Gittell JH, Lusenhop W, et al. Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surg…
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