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psnet.ahrq.gov/issue/critical-care-nurses-role-rapid-response-teams-qualitative-systematic-review
May 18, 2022 - Review
Critical care nurses' role in rapid response teams: a qualitative systematic review.
Citation Text:
Holtsmark C, Larsen MH, Steindal SA, et al. Critical care nurses' role in rapid response teams: a qualitative systematic review. J Clin Nurs. 2024;33(10):3831-3843. doi:10.1111/jocn…
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psnet.ahrq.gov/issue/impact-pharmacist-led-discharge-medication-reconciliation-error-and-patient-harm-prevention
March 27, 2019 - Study
Impact of pharmacist-led discharge medication reconciliation on error and patient harm prevention at a large academic medical center.
Citation Text:
Zheng L, Pon T, Bajorek SA, et al. Impact of pharmacist‐led discharge medication reconciliation on error and patient harm prevention …
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psnet.ahrq.gov/issue/how-unprofessional-behaviours-between-healthcare-staff-threaten-patient-care-and-safety
July 24, 2024 - Commentary
How unprofessional behaviours between healthcare staff threaten patient care and safety.
Citation Text:
Aunger J, Maben J, Westbrook JI. How unprofessional behaviours between healthcare staff threaten patient care and safety. Expert Rev Pharmacoecon Outcomes Res. 2025;Epub Jan…
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www.uspreventiveservicestaskforce.org/uspstf/prevention-taskforce-app-communications-toolkit
April 09, 2025 - Prevention TaskForce App Communications Toolkit
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Communications Toolkit The Prevention TaskForce (formerly ePSS) is an application designed to help primary care clinicians…
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psnet.ahrq.gov/issue/prevalence-wrong-level-surgery-among-spine-surgeons
March 09, 2022 - Study
The prevalence of wrong level surgery among spine surgeons.
Citation Text:
Mody MG, Nourbakhsh A, Stahl DL, et al. The prevalence of wrong level surgery among spine surgeons. Spine (Phila Pa 1976). 2008;33(2):194-198. doi:10.1097/BRS.0b013e31816043d1.
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psnet.ahrq.gov/issue/improving-quality-health-care-who-will-lead
June 14, 2011 - Commentary
Classic
Improving the quality of health care: who will lead?
Citation Text:
Becher EC, Chassin MR. Improving the quality of health care: who will lead? Health Aff (Millwood). 2001;20(5):164-79.
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psnet.ahrq.gov/issue/pharmacy-leadership-amid-pandemic-maintaining-patient-safety-during-uncertain-times
March 29, 2023 - Commentary
Pharmacy leadership amid the pandemic: maintaining patient safety during uncertain times.
Citation Text:
Derrong Lin I, Hertig JB. Pharmacy leadership amid the pandemic: maintaining patient safety during uncertain times. Hosp Pharm. 2022;57(3):323-328. doi:10.1177/001857872110…
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psnet.ahrq.gov/issue/impact-patient-safety-culture-missed-nursing-care-and-adverse-patient-events
March 16, 2022 - Study
Emerging Classic
Impact of patient safety culture on missed nursing care and adverse patient events.
Citation Text:
Hessels AJ, Paliwal M, Weaver SH, et al. Impact of Patient Safety Culture on Missed Nursing Care and Adverse Patient Events. J Nurs Care Qua…
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psnet.ahrq.gov/issue/incorporating-nursing-complexity-reimbursement-coding-systems-potential-impact-missed-care
September 28, 2022 - Commentary
Incorporating nursing complexity in reimbursement coding systems: the potential impact on missed care.
Citation Text:
Sasso L, Bagnasco A, Aleo G, et al. Incorporating nursing complexity in reimbursement coding systems: the potential impact on missed care. BMJ Qual Saf. 2017;2…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/experience-research/byrne-jm-et
January 01, 2023 - Byrne JM et al. 2009 "Initial experience with patient-clinician secure messaging at a VA medical center."
Reference
Byrne JM, Elliott S, Firek A. Initial experience with patient-clinician secure messaging at a VA medical center. J Am Med Inform Assoc 2009;16(2):267-270.
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Abstract
"The …
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digital.ahrq.gov/principal-investigator/mctigue-kathleen-m
January 01, 2023 - McTigue, Kathleen M.
Effect of electronic health record-based coaching on weight maintenance: a randomized trial.
Citation
Conroy MB, McTigue KM, Bryce CL, Tudorascu D, Barone Gibbs B, Arnold J, Comer D, Hess R, Huber K, Simkin-Silverman LR, Fischer GS. Effect of Electronic He…
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psnet.ahrq.gov/issue/limits-safety-organizations-accidents-and-nuclear-weapons
July 28, 2013 - Book/Report
Classic
The Limits of Safety: Organizations, Accidents and Nuclear Weapons.
Citation Text:
The Limits of Safety: Organizations, Accidents and Nuclear Weapons. Sagan SD. Princeton NJ: Princeton University Press; 1993. ISBN: 9780691032214.
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psnet.ahrq.gov/issue/public-sector-organizational-failure-study-collective-denial-uk-national-health-service
June 03, 2020 - Study
Public sector organizational failure: a study of collective denial in the UK national health service.
Citation Text:
Hendy J, Tucker DA. Public sector organizational failure: a study of collective denial in the UK national health service. J Bus Ethics. 2020;2021;172:691–706. doi:10…
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psnet.ahrq.gov/issue/framework-analysis-communication-errors-health-care
October 21, 2020 - Commentary
A framework for the analysis of communication errors in health care.
Citation Text:
Bender JA, Thiyagarajan S, Morrish W, et al. A framework for the analysis of communication errors in health care. J Patient Saf. 2025;21(2):69-81. doi:10.1097/pts.0000000000001303.
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www.ahrq.gov/programs/index.html
January 01, 2016 - Digital Healthcare Research Advancing healthcare quality, safety, and effectiveness through the evolving digital healthcare ecosystem. More
PSNet Discover the latest literature, news, and expert commentary on patient safety topics. More
CAHPS The CAHPS program aims to advance our scientific …
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psnet.ahrq.gov/issue/capturing-essential-information-achieve-safe-interoperability
February 23, 2015 - Commentary
Capturing essential information to achieve safe interoperability.
Citation Text:
Weininger S, Jaffe MB, Rausch T, et al. Capturing Essential Information to Achieve Safe Interoperability. Anesth Analg. 2017;124(1):83-94.
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psnet.ahrq.gov/issue/3-year-study-medication-incidents-acute-general-hospital
July 15, 2020 - Study
A 3-year study of medication incidents in an acute general hospital.
Citation Text:
Song L, Chui WCM, Lau CP, et al. A 3-year study of medication incidents in an acute general hospital. J Clin Pharm Ther. 2008;33(2):109-14. doi:10.1111/j.1365-2710.2007.00880.x.
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/dorr-d-et-al-2007
January 01, 2007 - Dorr D et al. 2007 "Informatics systems to promote improved care for chronic illness: a literature review."
Reference
Dorr D, Bonner LM, Cohen AN, et al. Informatics systems to promote improved care for chronic illness: a literature review. J Am Med Inform Assoc 2007;14(2):156-163.
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Abst…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/miller-ra-1994-medical
January 01, 1994 - Miller RA 1994 "Medical diagnostic decision-support systems - past, present, and future - a threaded bibliography and brief commentary."
Reference
Miller RA. Medical diagnostic decision-support systems - past, present, and future - a threaded bibliography and brief commentary. J Am Med Inform Assoc 19…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/currell-r-et-al-2000
January 01, 2000 - Currell R et al. 2000 "Telemedicine versus face to face patient care: effects on professional practice and health care outcomes."
Reference
Currell R, Urquhart C, Wainwright P, et al. Telemedicine versus face to face patient care: effects on professional practice and health care outcomes. Cochrane Da…