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  1. Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clinical and managerial priorities. | PSNet

    psnet.ahrq.gov/issue/beyond-clinical-engagement-pragmatic-model-quality-improvement-interventions-aligning
    April 24, 2018 - Review Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clinical and managerial priorities. Citation Text: Pannick S, Sevdalis N, Athanasiou T. Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clini…

  2. On the CUSP: Stop BSI: evaluating the relationship between central line–associated bloodstream infection rate and patient safety climate profile. | PSNet

    psnet.ahrq.gov/issue/cusp-stop-bsi-evaluating-relationship-between-central-line-associated-bloodstream-infection
    January 30, 2013 - Study On the CUSP: Stop BSI: evaluating the relationship between central line–associated bloodstream infection rate and patient safety climate profile. Citation Text: Weaver SJ, Weeks K, Pham JC, et al. On the CUSP: Stop BSI: evaluating the relationship between central line-associated bl…

  3. Operating room organization and surgical performance: a systematic review. | PSNet

    psnet.ahrq.gov/issue/operating-room-organization-and-surgical-performance-systematic-review
    March 05, 2025 - Review Operating room organization and surgical performance: a systematic review. Citation Text: Pasquer A, Ducarroz S, Lifante JC, et al. Operating room organization and surgical performance: a systematic review. Patient Saf Surg. 2024;18(1):5. doi:10.1186/s13037-023-00388-3. Copy Cit…

  4. A retrospective review of crisis events in diagnostic radiology: an analysis of frequency, demographics, etiologies, and outcomes. | PSNet

    psnet.ahrq.gov/issue/retrospective-review-crisis-events-diagnostic-radiology-analysis-frequency-demographics
    February 17, 2017 - Study A retrospective review of crisis events in diagnostic radiology: an analysis of frequency, demographics, etiologies, and outcomes. Citation Text: Tindel MS, Darby JM, Simmons RL. A retrospective review of crisis events in diagnostic radiology: an analysis of frequency, demographics…

  5. Towards a common framework to support decision-making in high-risk, low-time environments. | PSNet

    psnet.ahrq.gov/issue/towards-common-framework-support-decision-making-high-risk-low-time-environments
    November 16, 2022 - Commentary Towards a common framework to support decision-making in high-risk, low-time environments. Citation Text: Launder D, Penney G. Towards a common framework to support decision‐making in high‐risk, low‐time environments. J Contin Crisis Manag. 2023;31(4):862-876. doi:10.1111/1468…

  6. The impact of RVU-based compensation on patient safety outcomes in outpatient otolaryngology procedures. | PSNet

    psnet.ahrq.gov/issue/impact-rvu-based-compensation-patient-safety-outcomes-outpatient-otolaryngology-procedures
    October 19, 2022 - Study The impact of RVU-based compensation on patient safety outcomes in outpatient otolaryngology procedures. Citation Text: Stanisce L, Ahmad N, Deckard N, et al. The Impact of RVU-Based Compensation on Patient Safety Outcomes in Outpatient Otolaryngology Procedures. Otolaryngol Head N…

  7. Has the Leapfrog Group had an impact on the health care market? | PSNet

    psnet.ahrq.gov/issue/has-leapfrog-group-had-impact-health-care-market
    November 13, 2024 - Commentary Has the Leapfrog Group had an impact on the health care market? Citation Text: Galvin RS, Delbanco S, Milstein A, et al. Has the leapfrog group had an impact on the health care market? Health Aff (Millwood). 2005;24(1):228-33. Copy Citation Format: Google Schola…

  8. Inadequate preoperative team briefings lead to more intraoperative adverse events. | PSNet

    psnet.ahrq.gov/issue/inadequate-preoperative-team-briefings-lead-more-intraoperative-adverse-events
    June 07, 2023 - Study Inadequate preoperative team briefings lead to more intraoperative adverse events. Citation Text: Phadnis J, Templeton-Ward O. Inadequate Preoperative Team Briefings Lead to More Intraoperative Adverse Events. J Patient Saf. 2018;14(2):82-86. doi:10.1097/PTS.0000000000000181. Cop…

  9. Educational interventions to improve handover in health care: a systematic review. | PSNet

    psnet.ahrq.gov/issue/educational-interventions-improve-handover-health-care-systematic-review
    August 04, 2021 - Review Educational interventions to improve handover in health care: a systematic review. Citation Text: Gordon M, Findley R. Educational interventions to improve handover in health care: a systematic review. Med Educ. 2011;45(11):1081-9. doi:10.1111/j.1365-2923.2011.04049.x. Copy Ci…

  10. Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective survey. | PSNet

    psnet.ahrq.gov/issue/adequacy-information-transferred-resident-sign-out-hospital-handover-care-prospective-survey
    April 30, 2008 - Study Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective survey. Citation Text: Borowitz SM, Waggoner-Fountain LA, Bass EJ, et al. Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective …

  11. A framework for the analysis of communication errors in health care. | PSNet

    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. Copy Citat…

  12. Epidemiology of diagnostic errors in pediatric emergency departments using electronic triggers. | PSNet

    psnet.ahrq.gov/issue/epidemiology-diagnostic-errors-pediatric-emergency-departments-using-electronic-triggers
    December 16, 2020 - Study Epidemiology of diagnostic errors in pediatric emergency departments using electronic triggers. Citation Text: Mahajan P, White E, Shaw KN, et al. Epidemiology of diagnostic errors in pediatric emergency departments using electronic triggers. Acad Emerg Med. 2025;Epub Jan 15. doi:1…

  13. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2021. | PSNet

    psnet.ahrq.gov/issue/surviving-sepsis-campaign-international-guidelines-management-sepsis-and-septic-shock-2021
    September 25, 2013 - Clinical Guideline Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2021. Citation Text: Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med.…

  14. Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. | PSNet

    psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-fiscal-2021
    October 12, 2022 - Book/Report Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. Citation Text: Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. Washington, DC: Veterans Affairs Office of Inspector General; 2…

  15. Addressing racial and ethnic bias in pulse oximeters—a wicked problem. | PSNet

    psnet.ahrq.gov/issue/addressing-racial-and-ethnic-bias-pulse-oximeters-wicked-problem
    April 18, 2019 - Commentary Addressing racial and ethnic bias in pulse oximeters—a wicked problem. Citation Text: Shachar C, Drabo EF, Iwashyna TJ, et al. Addressing racial and ethnic bias in pulse oximeters—a wicked problem. JAMA. 2025;333(7):563-564. doi:10.1001/jama.2024.25443. Copy Citation For…

  16. Diagnostic safety: needs assessment and informed curriculum at an academic children's hospital. | PSNet

    psnet.ahrq.gov/issue/diagnostic-safety-needs-assessment-and-informed-curriculum-academic-childrens-hospital
    June 28, 2023 - Study Diagnostic safety: needs assessment and informed curriculum at an academic children's hospital. Citation Text: Congdon M, Rasooly IR, Toto RL, et al. Diagnostic safety: needs assessment and informed curriculum at an academic children's hospital. Pediatr Qual Saf. 2024;9(6):e773. do…

  17. Towards safer transitions: a curriculum to teach and assess hospital-to-hospice handoffs. | PSNet

    psnet.ahrq.gov/issue/towards-safer-transitions-curriculum-teach-and-assess-hospital-hospice-handoffs
    March 20, 2024 - Commentary Towards safer transitions: a curriculum to teach and assess hospital-to-hospice handoffs. Citation Text: Darrah NJ, O'Connor NR. Toward Safer Transitions: A Curriculum to Teach and Assess Hospital-to-Hospice Handoffs. J Pain Symptom Manage. 2016;51(6):959-962.e2. doi:10.1016/j…

  18. Partnering to prevent falls: using a multimodal multidisciplinary team. | PSNet

    psnet.ahrq.gov/issue/partnering-prevent-falls-using-multimodal-multidisciplinary-team
    June 22, 2010 - Commentary Partnering to prevent falls: using a multimodal multidisciplinary team. Citation Text: Volz TM, Swaim J. Partnering to prevent falls: using a multimodal multidisciplinary team. J Nurs Adm. 2013;43(6):336-41. doi:10.1097/NNA.0b013e3182942c5a. Copy Citation Format: …

  19. Diagnostic error in pediatrics: a narrative review. | PSNet

    psnet.ahrq.gov/issue/diagnostic-error-pediatrics-narrative-review
    June 08, 2022 - Review Diagnostic error in pediatrics: a narrative review. Citation Text: Marshall TL, Rinke ML, Olson APJ, et al. Diagnostic error in pediatrics: a narrative review. Pediatrics. 2022;149(Suppl 3):e2020045948D. doi:10.1542/peds.2020-045948d. Copy Citation Format: DOI Google…

  20. Artificial intelligence and healthcare: a journey through history, present innovations, and future possibilities. | PSNet

    psnet.ahrq.gov/issue/artificial-intelligence-and-healthcare-journey-through-history-present-innovations-and-future
    August 04, 2021 - Review Artificial intelligence and healthcare: a journey through history, present innovations, and future possibilities. Citation Text: Hirani R, Noruzi K, Khuram H, et al. Artificial intelligence and healthcare: a journey through history, present innovations, and future possibilities. L…
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