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  1. Operational measurement of diagnostic safety: state of the science. | PSNet

    psnet.ahrq.gov/issue/operational-measurement-diagnostic-safety-state-science-0
    September 28, 2022 - Commentary Emerging Classic Operational measurement of diagnostic safety: state of the science. Citation Text: Singh H, Bradford A, Goeschel CA. Operational measurement of diagnostic safety: state of the science. Diagnosis (Berl). 2021;8(1):51-66. doi:10.1515/dx…

  2. The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study. | PSNet

    psnet.ahrq.gov/issue/influence-organizational-context-quality-improvement-and-patient-safety-efforts-infection
    May 08, 2017 - Study The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study. Citation Text: Krein SL, Damschroder LJ, Kowalski CP, et al. The influence of organizational context on quality improvement and pat…

  3. The role of emotion in patient safety: are we brave enough to scratch beneath the surface? | PSNet

    psnet.ahrq.gov/issue/role-emotion-patient-safety-are-we-brave-enough-scratch-beneath-surface
    January 09, 2014 - Review The role of emotion in patient safety: are we brave enough to scratch beneath the surface? Citation Text: Heyhoe J, Birks Y, Harrison R, et al. The role of emotion in patient safety: Are we brave enough to scratch beneath the surface? J R Soc Med. 2016;109(2):52-8. doi:10.1177/014…

  4. What is safety leadership? A systematic review of definitions. | PSNet

    psnet.ahrq.gov/issue/what-safety-leadership-systematic-review-definitions
    October 26, 2022 - Review What is safety leadership? A systematic review of definitions. Citation Text: Adra I, Giga S, Hardy C, et al. What is safety leadership? A systematic review of definitions. J Safety Res. 2024;90:181-191. doi:10.1016/j.jsr.2024.04.001. Copy Citation Format: DOI Google…

  5. Hospital commitments to address diagnostic errors: an assessment of 95 US hospitals. | PSNet

    psnet.ahrq.gov/issue/hospital-commitments-address-diagnostic-errors-assessment-95-us-hospitals
    September 18, 2024 - Study Hospital commitments to address diagnostic errors: an assessment of 95 US hospitals. Citation Text: Campione Russo A, Tilly J‐L, Kaufman L, et al. Hospital commitments to address diagnostic errors: an assessment of 95 US hospitals. J Hosp Med. 2025;20(2):120-134. doi:10.1002/jhm.13…

  6. Development of patient safety measures to identify inappropriate diagnosis of common infections. | PSNet

    psnet.ahrq.gov/issue/development-patient-safety-measures-identify-inappropriate-diagnosis-common-infections
    April 10, 2024 - Study Development of patient safety measures to identify inappropriate diagnosis of common infections. Citation Text: White AT, Vaughn VM, Petty LA, et al. Development of patient safety measures to identify inappropriate diagnosis of common infections. Clin Infect Dis. 2024;78(6):1403-14…

  7. An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions. | PSNet

    psnet.ahrq.gov/issue/evidence-based-toolkit-development-effective-and-sustainable-root-cause-analysis-system
    June 01, 2019 - Study An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions. Citation Text: Hettinger Z, Fairbanks RJ, Hegde S, et al. An evidence-based toolkit for the development of effective and sustainable root cause analysis syste…

  8. Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. | PSNet

    psnet.ahrq.gov/issue/feedback-loop-failure-modes-medical-diagnosis-how-biases-can-emerge-and-be-reinforced
    November 01, 2023 - Study Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. Citation Text: Aikens RC, Chen JH, Baiocchi M, et al. Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. Med Decis Making. 2024;44(5):481-496. doi:10.1…

  9. The time is now: addressing implicit bias in obstetrics and gynecology education. | PSNet

    psnet.ahrq.gov/issue/time-now-addressing-implicit-bias-obstetrics-and-gynecology-education
    November 16, 2022 - Commentary The time is now: addressing implicit bias in obstetrics and gynecology education. Citation Text: Royce CS, Morgan HK, Baecher-Lind L, et al. The time is now: addressing implicit bias in obstetrics and gynecology education. Am J Obstet Gynecol. 2023;228(4):369-381. doi:10.1016/…

  10. Stop the line: interventions to prevent retained surgical items. | PSNet

    psnet.ahrq.gov/issue/stop-line-interventions-prevent-retained-surgical-items
    July 10, 2024 - Commentary Stop the line: interventions to prevent retained surgical items. Citation Text: Angelilli S. Stop the line: interventions to prevent retained surgical items. AORN J. 2024;120(2):71-81. doi:10.1002/aorn.14190. Copy Citation Format: DOI Google Scholar BibTeX EndNot…

  11. Formal medicine reconciliation within the emergency department reduces the medication error rates for emergency admissions. | PSNet

    psnet.ahrq.gov/issue/formal-medicine-reconciliation-within-emergency-department-reduces-medication-error-rates
    May 01, 2019 - Study Formal medicine reconciliation within the emergency department reduces the medication error rates for emergency admissions. Citation Text: Mills PR, McGuffie AC. Formal medicine reconciliation within the emergency department reduces the medication error rates for emergency admiss…

  12. What is the evidence that a pharmacy team working in an acute or emergency medicine department improves outcomes for patients: a systematic review. | PSNet

    psnet.ahrq.gov/issue/what-evidence-pharmacy-team-working-acute-or-emergency-medicine-department-improves-outcomes
    August 10, 2022 - Review What is the evidence that a pharmacy team working in an acute or emergency medicine department improves outcomes for patients: a systematic review. Citation Text: Punj E, Collins A, Agravedi N, et al. What is the evidence that a pharmacy team working in an acute or emergency medic…

  13. Communication of preclinical emergency teams in critical situations: a nationwide study. | PSNet

    psnet.ahrq.gov/issue/communication-preclinical-emergency-teams-critical-situations-nationwide-study
    January 23, 2019 - Study Communication of preclinical emergency teams in critical situations: a nationwide study. Citation Text: Zimmer M, Czarniecki DM, Sahm S. Communication of preclinical emergency teams in critical situations: a nationwide study. PLoS One. 2021;16(5):e0250932. doi:10.1371/journal.pone.…

  14. Increasing reporting of adverse events to improve the educational value of the morbidity and mortality conference. | PSNet

    psnet.ahrq.gov/issue/increasing-reporting-adverse-events-improve-educational-value-morbidity-and-mortality
    February 04, 2016 - Study Increasing reporting of adverse events to improve the educational value of the morbidity and mortality conference. Citation Text: McVeigh TP, Waters PS, Murphy R, et al. Increasing reporting of adverse events to improve the educational value of the morbidity and mortality confere…

  15. An overview of intravenous-related medication administration errors as reported to MEDMARX(R), a national medication error-reporting program. | PSNet

    psnet.ahrq.gov/issue/overview-intravenous-related-medication-administration-errors-reported-medmarxr-national
    April 14, 2021 - Study An overview of intravenous-related medication administration errors as reported to MEDMARX(R), a national medication error-reporting program. Citation Text: Hicks RW, Becker SC. An overview of intravenous-related medication administration errors as reported to MEDMARX, a national…

  16. Medication reconciliation: comparing a customized medication history form to a standard medication form in a specialty clinic (CAMPII 2). | PSNet

    psnet.ahrq.gov/issue/medication-reconciliation-comparing-customized-medication-history-form-standard-medication
    September 23, 2020 - Study Medication reconciliation: comparing a customized medication history form to a standard medication form in a specialty clinic (CAMPII 2). Citation Text: Ryan GJ, Caudle JM, Rhee MK, et al. Medication reconciliation: comparing a customized medication history form to a standard medi…

  17. Adverse events detected by clinical surveillance on an obstetric service. | PSNet

    psnet.ahrq.gov/issue/adverse-events-detected-clinical-surveillance-obstetric-service
    September 11, 2009 - Study Adverse events detected by clinical surveillance on an obstetric service. Citation Text: Forster AJ, Fung I, Caughey S, et al. Adverse events detected by clinical surveillance on an obstetric service. Obstet Gynecol. 2006;108(5):1073-83. Copy Citation Format: Google…

  18. Hospital workload and adverse events. | PSNet

    psnet.ahrq.gov/issue/hospital-workload-and-adverse-events
    August 31, 2011 - Study Classic Hospital workload and adverse events. Citation Text: Weissman JS, Rothschild JM, Bendavid E, et al. Hospital workload and adverse events. Med Care. 2007;45(5):448-55. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML…

  19. Usability evaluation of order sets in a computerized provider order entry system. | PSNet

    psnet.ahrq.gov/issue/usability-evaluation-order-sets-computerized-provider-order-entry-system
    May 04, 2011 - Study Usability evaluation of order sets in a computerized provider order entry system. Citation Text: Chan J, Shojania KG, Easty AC, et al. Usability evaluation of order sets in a computerised provider order entry system. BMJ Qual Saf. 2011;20(11):932-40. doi:10.1136/bmjqs.2010.050021…

  20. Care at the point of impact: insights into the second-victim experience. | PSNet

    psnet.ahrq.gov/issue/care-point-impact-insights-second-victim-experience
    January 03, 2017 - Commentary Care at the point of impact: insights into the second-victim experience. Citation Text: Scott SD, McCoig MM. Care at the point of impact: Insights into the second-victim experience. J Healthc Risk Manag. 2016;35(4):6-13. doi:10.1002/jhrm.21218. Copy Citation Format: …
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