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  1. Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence. | PSNet

    psnet.ahrq.gov/issue/linking-joint-commission-inpatient-core-measures-and-national-patient-safety-goals-evidence
    October 19, 2022 - Commentary Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence. Citation Text: Masica AL, Richter KM, Convery P, et al. Linking joint commission inpatient core measures and national patient safety goals with evidence. Proc (Bayl Univ Med Cen…

  2. FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that accidental exposure to used patches can cause death. | PSNet

    psnet.ahrq.gov/issue/fda-requiring-color-changes-duragesic-fentanyl-pain-patches-aid-safety-emphasizing-accidental
    August 05, 2020 - Press Release/Announcement FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that accidental exposure to used patches can cause death. Citation Text: FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that…

  3. The effect of staff nurses' shift length and fatigue on patient safety and nurses' health: from the National Association of Neonatal Nurses. | PSNet

    psnet.ahrq.gov/issue/effect-staff-nurses-shift-length-and-fatigue-patient-safety-and-nurses-health-national
    July 06, 2011 - Commentary The effect of staff nurses' shift length and fatigue on patient safety and nurses' health: from the National Association of Neonatal Nurses. Citation Text: Samra HA, Smith BA. The Effect of Staff Nurses' Shift Length and Fatigue on Patient Safety and Nurses' Health: From the N…

  4. Simulation-based education to train learners to "speak up" in the clinical environment: results of a randomized trial. | PSNet

    psnet.ahrq.gov/issue/simulation-based-education-train-learners-speak-clinical-environment-results-randomized-trial
    September 27, 2023 - Study Simulation-based education to train learners to "speak up" in the clinical environment: results of a randomized trial. Citation Text: Oner C, Fisher N, Atallah F, et al. Simulation-Based Education to Train Learners to "Speak Up" in the Clinical Environment: Results of a Randomized …

  5. Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety. | PSNet

    psnet.ahrq.gov/issue/safety-measurement-and-monitoring-healthcare-framework-guide-clinical-teams-and-healthcare
    September 24, 2018 - Review Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety. Citation Text: Vincent CA, Burnett S, Carthey J. Safety measurement and monitoring in healthcare: a framework to guide clinical teams and health…

  6. Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. | PSNet

    psnet.ahrq.gov/issue/thoughtless-design-electronic-health-record-drives-overuse-purposeful-design-can-nudge
    July 17, 2024 - Commentary Emerging Classic Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. Citation Text: Vaughn VM, Linder JA. Thoughtless design of the electronic health record drives overuse, but purp…

  7. Board quality scorecards: measuring improvement. | PSNet

    psnet.ahrq.gov/issue/board-quality-scorecards-measuring-improvement
    June 16, 2011 - Study Board quality scorecards: measuring improvement. Citation Text: Goeschel CA, Berenholtz SM, Culbertson R, et al. Board quality scorecards: measuring improvement. Am J Med Qual. 2011;26(4):254-60. doi:10.1177/1062860610389324. Copy Citation Format: DOI Google Scholar…

  8. Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety. | PSNet

    psnet.ahrq.gov/issue/commissioning-simulations-test-new-healthcare-facilities-proactive-and-innovative-approach
    September 30, 2020 - Commentary Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety. Citation Text: Kaba A, Barnes S. Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system …

  9. Composite measures for profiling hospitals on bariatric surgery performance. | PSNet

    psnet.ahrq.gov/issue/composite-measures-profiling-hospitals-bariatric-surgery-performance
    January 31, 2013 - Study Composite measures for profiling hospitals on bariatric surgery performance. Citation Text: Dimick JB, Birkmeyer NJ, Finks JF, et al. Composite measures for profiling hospitals on bariatric surgery performance. JAMA Surg. 2014;149(1):10-6. doi:10.1001/jamasurg.2013.4109. Copy Cit…

  10. Multiple interacting factors influence adherence, and outcomes associated with surgical safety checklists: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/multiple-interacting-factors-influence-adherence-and-outcomes-associated-surgical-safety
    June 21, 2016 - Study Multiple interacting factors influence adherence, and outcomes associated with surgical safety checklists: a qualitative study. Citation Text: Gagliardi AR, Straus SE, Shojania KG, et al. Multiple interacting factors influence adherence, and outcomes associated with surgical safety…

  11. Challenges of implementing a communication-and-resolution program where multiple organizations must cooperate. | PSNet

    psnet.ahrq.gov/issue/challenges-implementing-communication-and-resolution-program-where-multiple-organizations
    May 11, 2016 - Study Challenges of implementing a communication-and-resolution program where multiple organizations must cooperate. Citation Text: Mello MM, Armstrong S, Greenberg Y, et al. Challenges of Implementing a Communication-and-Resolution Program Where Multiple Organizations Must Cooperate. He…

  12. The association between patient safety indicators and medical malpractice risk: evidence from Florida and Texas. | PSNet

    psnet.ahrq.gov/issue/association-between-patient-safety-indicators-and-medical-malpractice-risk-evidence-florida
    September 28, 2022 - Study The association between patient safety indicators and medical malpractice risk: evidence from Florida and Texas. Citation Text: Black BS, Wagner AR, Zabinski Z. The Association between Patient Safety Indicators and Medical Malpractice Risk: Evidence from Florida and Texas. Am J Hea…

  13. Impact of organizational leadership on physician burnout and satisfaction. | PSNet

    psnet.ahrq.gov/issue/impact-organizational-leadership-physician-burnout-and-satisfaction
    June 28, 2010 - Study Impact of organizational leadership on physician burnout and satisfaction. Citation Text: Shanafelt TD, Gorringe G, Menaker R, et al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90(4):432-40. doi:10.1016/j.mayocp.2015.01.012. Co…

  14. Implicit racial bias in pediatric orthopaedic surgery. | PSNet

    psnet.ahrq.gov/issue/implicit-racial-bias-pediatric-orthopaedic-surgery
    September 21, 2022 - Study Implicit racial bias in pediatric orthopaedic surgery. Citation Text: Guzek R, Goodbody CM, Jia L, et al. Implicit racial bias in pediatric orthopaedic surgery. J Pediatr Orthop. 2022;42(7):393-399. doi:10.1097/bpo.0000000000002170. Copy Citation Format: DOI Google Sc…

  15. Responding to unprofessional behavior by trainees - a "just culture" framework. | PSNet

    psnet.ahrq.gov/issue/responding-unprofessional-behavior-trainees-just-culture-framework
    June 24, 2020 - Commentary Responding to unprofessional behavior by trainees - a "just culture" framework. Citation Text: Wasserman JA, Redinger M, Gibb T. Responding to Unprofessional Behavior by Trainees — A “Just Culture” Framework. New England Journal of Medicine. 2020;382(8). doi:10.1056/nejmms191…

  16. Misuse of pediatric medications and parent–physician communication: an interactive voice response intervention. | PSNet

    psnet.ahrq.gov/issue/misuse-pediatric-medications-and-parent-physician-communication-interactive-voice-response
    May 27, 2011 - Study Misuse of pediatric medications and parent–physician communication: an interactive voice response intervention. Citation Text: Walsh KE, Bacic J, Phillips BD, et al. Misuse of Pediatric Medications and Parent-Physician Communication: An Interactive Voice Response Intervention. J Pa…

  17. Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. | PSNet

    psnet.ahrq.gov/issue/using-performance-improvement-enhance-time-out-compliance-and-prevent-wrong-site-surgery
    October 06, 2021 - Commentary Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. Citation Text: Vance ME, Proctor T, Schmidt KA. Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. AORN J. 2021;113(6):635-642. doi:10.1002/ao…

  18. Coping with errors in the operating room: intraoperative strategies, postoperative strategies, and sex differences. | PSNet

    psnet.ahrq.gov/issue/coping-errors-operating-room-intraoperative-strategies-postoperative-strategies-and-sex
    September 09, 2020 - Study Coping with errors in the operating room: intraoperative strategies, postoperative strategies, and sex differences. Citation Text: D'Angelo JD, Lund S, Busch RA, et al. Coping with errors in the operating room: intraoperative strategies, postoperative strategies, and sex difference…

  19. Gender biases and diagnostic delay in inflammatory bowel disease: multicenter observational study. | PSNet

    psnet.ahrq.gov/issue/gender-biases-and-diagnostic-delay-inflammatory-bowel-disease-multicenter-observational-study
    March 09, 2022 - Study Gender biases and diagnostic delay in inflammatory bowel disease: multicenter observational study. Citation Text: Sempere L, Bernabeu P, Cameo J, et al. Gender biases and diagnostic delay in inflammatory bowel disease: multicenter observational study. Inflamm Bowel Dis. 2023;29(12)…

  20. Communicating doses of pediatric liquid medicines to parents/caregivers: a comparison of written dosing directions on prescriptions with labels applied by dispensed pharmacy. | PSNet

    psnet.ahrq.gov/issue/communicating-doses-pediatric-liquid-medicines-parentscaregivers-comparison-written-dosing
    July 10, 2024 - Study Communicating doses of pediatric liquid medicines to parents/caregivers: a comparison of written dosing directions on prescriptions with labels applied by dispensed pharmacy. Citation Text: Shah R, Blustein L, Kuffner E, et al. Communicating doses of pediatric liquid medicines to p…
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