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  1. A mixed methods study exploring patient safety culture at 4 VHA Hospitals. | PSNet

    psnet.ahrq.gov/issue/mixed-methods-study-exploring-patient-safety-culture-4-vha-hospitals
    September 25, 2019 - Study A mixed methods study exploring patient safety culture at 4 VHA Hospitals. Citation Text: Sullivan JL, Shin MH, Ranusch A, et al. A mixed methods study exploring patient safety culture at 4 VHA Hospitals. Jt Comm J Qual Patient Saf. 2024;50(11):791-800. doi:10.1016/j.jcjq.2024.07.0…

  2. Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings. | PSNet

    psnet.ahrq.gov/issue/publication-inspection-frameworks-qualitative-study-exploring-impact-quality-improvement-and
    August 10, 2022 - Study Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings. Citation Text: Weenink J-W, Wallenburg I, Leistikow I, et al. Publication of inspection frameworks: a qualitative study exploring the i…

  3. Assessment of overuse of medical tests and treatments at US hospitals using Medicare claims. | PSNet

    psnet.ahrq.gov/issue/assessment-overuse-medical-tests-and-treatments-us-hospitals-using-medicare-claims
    August 11, 2021 - Study Assessment of overuse of medical tests and treatments at US hospitals using Medicare claims. Citation Text: Chalmers K, Smith P, Garber J, et al. Assessment of overuse of medical tests and treatments at US hospitals using Medicare claims. JAMA Netw Open. 2021;4(4):e218075. doi:10.1…

  4. Screening electronic health record–related patient safety reports using machine learning. | PSNet

    psnet.ahrq.gov/issue/screening-electronic-health-record-related-patient-safety-reports-using-machine-learning
    May 30, 2016 - Study Screening electronic health record–related patient safety reports using machine learning. Citation Text: Marella WM, Sparnon E, Finley E. Screening Electronic Health Record–Related Patient Safety Reports Using Machine Learning. J Patient Saf. 2014;13(1):31-36. doi:10.1097/pts.00000…

  5. Beyond 'find and fix': improving quality and safety through resilient healthcare systems. | PSNet

    psnet.ahrq.gov/issue/beyond-find-and-fix-improving-quality-and-safety-through-resilient-healthcare-systems
    August 04, 2021 - Study Beyond 'find and fix': improving quality and safety through resilient healthcare systems. Citation Text: Anderson JE, Ross AJ, Back J, et al. Beyond ‘find and fix’: improving quality and safety through resilient healthcare systems. Int J Qual Health Care. 2020;32(3):204-211. doi:10…

  6. Preserving organizational resilience, patient safety, and staff retention during COVID-19 requires a holistic consideration of the psychological safety of healthcare workers | PSNet

    psnet.ahrq.gov/issue/preserving-organizational-resilience-patient-safety-and-staff-retention-during-covid-19
    May 08, 2019 - Commentary Classic Preserving organizational resilience, patient safety, and staff retention during COVID-19 requires a holistic consideration of the psychological safety of healthcare workers Citation Text: Rangachari P, L. Woods J. Preserving organizational re…

  7. From box ticking to the black box: the evolution of operating room safety. | PSNet

    psnet.ahrq.gov/issue/box-ticking-black-box-evolution-operating-room-safety
    October 29, 2017 - Commentary From box ticking to the black box: the evolution of operating room safety. Citation Text: Goldenberg MG, Elterman D. From box ticking to the black box: the evolution of operating room safety. World J Urol. 2019;38(6):1369-1372. doi:10.1007/s00345-019-02886-5. Copy Citation …

  8. Controversies in diagnosis: contemporary debates in the diagnostic safety literature. | PSNet

    psnet.ahrq.gov/issue/controversies-diagnosis-contemporary-debates-diagnostic-safety-literature
    December 21, 2018 - Review Controversies in diagnosis: contemporary debates in the diagnostic safety literature. Citation Text: Bergl PA, Wijesekera TP, Nassery N, et al. Controversies in diagnosis: contemporary debates in the diagnostic safety literature. Diagnosis (Berl). 2020;7(1):3-9. doi:10.1515/dx-201…

  9. Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme. | PSNet

    psnet.ahrq.gov/issue/striving-high-reliability-healthcare-qualitative-study-implementation-hospital-safety
    July 10, 2019 - Study Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme. Citation Text: Rotteau L, Goldman J, Shojania KG, et al. Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safet…

  10. Hospital-acquired SARS-CoV-2 infection: lessons for public health. | PSNet

    psnet.ahrq.gov/issue/hospital-acquired-sars-cov-2-infection-lessons-public-health
    November 25, 2020 - Commentary Hospital-acquired SARS-CoV-2 infection: lessons for public health. Citation Text: Richterman A, Meyerowitz EA, Cevik M. Hospital-acquired SARS-CoV-2 infection: lessons for public health. JAMA. 2020;324(21):2155. doi:10.1001/jama.2020.21399. Copy Citation Format: …

  11. Community-acquired and hospital-acquired medication harm among older inpatients and impact of a state-wide medication management intervention. | PSNet

    psnet.ahrq.gov/issue/community-acquired-and-hospital-acquired-medication-harm-among-older-inpatients-and-impact
    August 28, 2024 - Study Community-acquired and hospital-acquired medication harm among older inpatients and impact of a state-wide medication management intervention. Citation Text: Pellegrin K, Lozano A, Miyamura J, et al. Community-acquired and hospital-acquired medication harm among older inpatients an…

  12. Fighting a common enemy: a catalyst to close intractable safety gaps. | PSNet

    psnet.ahrq.gov/issue/fighting-common-enemy-catalyst-close-intractable-safety-gaps
    June 30, 2021 - Commentary Fighting a common enemy: a catalyst to close intractable safety gaps. Citation Text: Singh H, Sittig DF, Gandhi TK. Fighting a common enemy: a catalyst to close intractable safety gaps. BMJ Qual Saf. 2021;30(2):141-145. doi:10.1136/bmjqs-2020-011390. Copy Citation Format…

  13. Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration. | PSNet

    psnet.ahrq.gov/issue/errors-upstream-and-downstream-universal-protocol-associated-wrong-surgery-events-veterans
    November 21, 2012 - Study Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration. Citation Text: Paull DE, Mazzia L, Neily J, et al. Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in t…

  14. Clinic design for safety during the pandemic: safety or teamwork, can we only pick one? | PSNet

    psnet.ahrq.gov/issue/clinic-design-safety-during-pandemic-safety-or-teamwork-can-we-only-pick-one
    November 11, 2015 - Commentary Clinic design for safety during the pandemic: safety or teamwork, can we only pick one? Citation Text: Lim L, Zimring CM, DuBose JR, et al. Clinic design for safety during the pandemic: safety or teamwork, can we only pick one? HERD. 2022;15(3):28-41. doi:10.1177/1937586722109…

  15. Reducing the risk of diagnostic error in the COVID-19 era. | PSNet

    psnet.ahrq.gov/issue/reducing-risk-diagnostic-error-covid-19-era
    September 23, 2020 - Commentary Emerging Classic Reducing the risk of diagnostic error in the COVID-19 era. Citation Text: Gandhi TK, Singh H. Reducing the risk of diagnostic error in the COVID-19 era. J. Hosp Med. 2020;15(6):363-366. doi:10.12788/jhm.3461. Copy Citation Forma…

  16. Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri. | PSNet

    psnet.ahrq.gov/issue/deficiencies-inpatient-mental-health-care-coordination-and-processes-prior-patients-death
    May 26, 2021 - Book/Report Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri. Citation Text: Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a…

  17. Fall prevention implementation strategies in use at 60 United States hospitals: a descriptive study. | PSNet

    psnet.ahrq.gov/issue/fall-prevention-implementation-strategies-use-60-united-states-hospitals-descriptive-study
    November 11, 2020 - Study Fall prevention implementation strategies in use at 60 United States hospitals: a descriptive study. Citation Text: Turner K, Staggs V, Potter C, et al. Fall prevention implementation strategies in use at 60 United States hospitals: a descriptive study. BMJ Qual Saf. 2020;29(12):10…

  18. The National Healthcare Safety Network's digital quality measures: CDC's automated measures for surveillance of patient safety. | PSNet

    psnet.ahrq.gov/issue/national-healthcare-safety-networks-digital-quality-measures-cdcs-automated-measures
    September 23, 2020 - Study The National Healthcare Safety Network's digital quality measures: CDC's automated measures for surveillance of patient safety. Citation Text: Shehab N, Alschuler L, McILvenna S, et al. The National Healthcare Safety Network’s digital quality measures: CDC’s automated measures for …

  19. Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee. | PSNet

    psnet.ahrq.gov/issue/care-deficiencies-and-leaders-inadequate-reviews-patient-who-died-lt-col-luke-weathers-jr-va
    April 10, 2024 - Book/Report Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee. Citation Text: Care Deficiencies and Leaders' Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Me…

  20. Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. | PSNet

    psnet.ahrq.gov/issue/improving-situation-awareness-reduce-unrecognized-clinical-deterioration-and-serious-safety
    December 02, 2014 - Study Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. Citation Text: Brady PW, Muething S, Kotagal U, et al. Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. Pediatrics. 2013;131(…
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