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  1. An evidence synthesis on perioperative handoffs: a call for balanced sociotechnical solutions. | PSNet

    psnet.ahrq.gov/issue/evidence-synthesis-perioperative-handoffs-call-balanced-sociotechnical-solutions
    June 23, 2021 - Review An evidence synthesis on perioperative handoffs: a call for balanced sociotechnical solutions. Citation Text: Abraham J, Duffy C, Kandasamy M, et al. An evidence synthesis on perioperative handoffs: a call for balanced sociotechnical solutions. Int J Med Inform. 2023;174:105038. d…

  2. CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting. | PSNet

    psnet.ahrq.gov/issue/cancelrx-health-it-tool-reduce-medication-discrepancies-outpatient-setting
    March 23, 2022 - Study CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting. Citation Text: Watterson TL, Stone JA, Brown RL, et al. CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting. J Am Med Inform Assoc. 2021;28(7):1526-1533. doi…

  3. 10,000 good catches: increasing safety event reporting in a pediatric health care system. | PSNet

    psnet.ahrq.gov/issue/10000-good-catches-increasing-safety-event-reporting-pediatric-health-care-system
    April 20, 2022 - Study 10,000 good catches: increasing safety event reporting in a pediatric health care system. Citation Text: Crandall KM, Almuhanna A, Cady R, et al. 10,000 Good Catches: Increasing Safety Event Reporting In A Pediatric Health Care System. Pediatr Qual Saf. 2019;3(2):e072. doi:10.1097/…

  4. Designing an abstraction instrument: lessons from efforts to validate the AHRQ Patient Safety Indicators. | PSNet

    psnet.ahrq.gov/issue/designing-abstraction-instrument-lessons-efforts-validate-ahrq-patient-safety-indicators
    January 13, 2010 - Commentary Designing an abstraction instrument: lessons from efforts to validate the AHRQ Patient Safety Indicators. Citation Text: Utter GH, Borzecki A, Rosen AK, et al. Designing an abstraction instrument: lessons from efforts to validate the AHRQ patient safety indicators. Jt Comm J Q…

  5. Association between surgeon stress and major surgical complications. | PSNet

    psnet.ahrq.gov/issue/association-between-surgeon-stress-and-major-surgical-complications
    November 29, 2023 - Study Association between surgeon stress and major surgical complications. Citation Text: Awtry J, Skinner S, Polazzi S, et al. Association between surgeon stress and major surgical complications. JAMA Surg. 2025;160(3):332-340. doi:10.1001/jamasurg.2024.6072. Copy Citation Format:…

  6. Understanding factors influencing safety and team functionality at operative vaginal birth through multidisciplinary perspectives: a mixed methods study. | PSNet

    psnet.ahrq.gov/issue/understanding-factors-influencing-safety-and-team-functionality-operative-vaginal-birth
    September 01, 2016 - Study Understanding factors influencing safety and team functionality at operative vaginal birth through multidisciplinary perspectives: a mixed methods study. Citation Text: Skinner SM, Kippen E, Rolnik DL, et al. Understanding factors influencing safety and team functionality at operat…

  7. The relationship between high-reliability practice and hospital-acquired conditions among the Solutions for Patient Safety Collaborative. | PSNet

    psnet.ahrq.gov/issue/relationship-between-high-reliability-practice-and-hospital-acquired-conditions-among
    March 20, 2019 - Study The relationship between high-reliability practice and hospital-acquired conditions among the Solutions for Patient Safety Collaborative. Citation Text: Randall KH, Slovensky D, Weech-Maldonado R, et al. The relationship between high-reliability practice and hospital-acquired condi…

  8. Variations by state in physician disciplinary actions by US medical licensure boards. | PSNet

    psnet.ahrq.gov/issue/variations-state-physician-disciplinary-actions-us-medical-licensure-boards
    March 12, 2025 - Study Variations by state in physician disciplinary actions by US medical licensure boards. Citation Text: Harris JA, Byhoff E. Variations by state in physician disciplinary actions by US medical licensure boards. BMJ Qual Saf. 2017;26(3):200-208. doi:10.1136/bmjqs-2015-004974. Copy Ci…

  9. The necessary leadership skillsets for the high-reliability organization framework adoption within acute healthcare organizations. | PSNet

    psnet.ahrq.gov/issue/necessary-leadership-skillsets-high-reliability-organization-framework-adoption-within-acute
    March 23, 2022 - Study The necessary leadership skillsets for the high-reliability organization framework adoption within acute healthcare organizations. Citation Text: Logan‐Athmer AL. The necessary leadership skillsets for the high‐reliability organization framework adoption within acute healthcare org…

  10. Promising Areas for Patient Safety Research | PSNet

    psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
    November 02, 2016 - significant promise to address the patient safety risks associated with clinical laboratory processes by identifying

  11. A Room Without Orders | PSNet

    psnet.ahrq.gov/web-mm/room-without-orders
    September 01, 2011 - The nurse manager is responsible for identifying factors that prevent staff from adhering to established

  12. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations | PSNet

    psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
    October 27, 2022 - Use caution when using CDC’s OME ratios in settings outside their intended use, which was for identifying

  13. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet

    psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
    September 24, 2024 - And when an event does occur, they focus on understanding the root causes and identifying corrective

  14. The Need to Eat | PSNet

    psnet.ahrq.gov/web-mm/need-eat
    February 10, 2021 - The Need to Eat Citation Text: Widaman AM. The Need to Eat. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50755/psn-pdf
    December 18, 2019 - The Need to Eat December 18, 2019 Widaman AM. The Need to Eat. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/need-eat The Case A 62-year-old man with a history of Wernicke–Korsakoff encephalopathy – a degenerative brain disorder caused by the lack of vitamin B1 – was admitted for possible aspiration pneum…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33858/psn-pdf
    May 01, 2018 - In Conversation With… John Halamka, MD, MS May 1, 2018 In Conversation With… John Halamka, MD, MS. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms Editor's note: Dr. Halamka is the International Healthcare Innovation Professor at Harvard Medical School, Chief Information …

  17. The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications | PSNet

    psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
    July 23, 2024 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications Save Save to your library Print Download PDF Sha…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73398/psn-pdf
    June 30, 2021 - architects and engineers of these healthcare environments are going to have to know much more about identifying

  19. In Conversation With... Freya Spielberg, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
    September 28, 2022 - In my research, I've worked on identifying new strategies to deliver services to address health disparities … diabetes, hypertension) make up the majority of deaths among minority racial and ethnic groups. 31 Identifying

  20. Syringe Swap During Regional Block: A Case of Medication Error and Recovery | PSNet

    psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
    July 22, 2020 - The providers involved in this incident should be credited for their vigilance in rapidly identifying
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