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psnet.ahrq.gov/issue/using-change-model-reduce-risk-surgical-site-infection
June 06, 2018 - Commentary
Using a change model to reduce the risk of surgical site infection.
Citation Text:
Burden M. Using a change model to reduce the risk of surgical site infection. Br J Nurs. 2016;25(17):949-955.
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psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-improving-safety-iv-drug-administration
March 23, 2012 - Study
Use of failure mode and effects analysis in improving the safety of i.v. drug administration.
Citation Text:
Adachi W, Lodolce AE. Use of failure mode and effects analysis in improving the safety of i.v. drug administration. Am J Health Syst Pharm. 2005;62(9):917-20.
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psnet.ahrq.gov/issue/safety-culture-healthcare-review-concepts-dimensions-measures-and-progress
November 21, 2014 - Review
Safety culture in healthcare: a review of concepts, dimensions, measures and progress.
Citation Text:
Halligan M, Zecevic A. Safety culture in healthcare: a review of concepts, dimensions, measures and progress. BMJ Qual Saf. 2011;20(4):338-43. doi:10.1136/bmjqs.2010.040964.
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psnet.ahrq.gov/issue/interruptions-and-geographic-challenges-nurses-cognitive-workload
March 20, 2019 - Study
Interruptions and geographic challenges to nurses' cognitive workload.
Citation Text:
Redding DA, Robinson S. Interruptions and geographic challenges to nurses' cognitive workload. J Nurs Care Qual. 2009;24(3):194-200; quiz 201-202. doi:10.1097/01.NCQ.0000356907.95076.31.
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psnet.ahrq.gov/issue/dental-patient-safety-military-health-system-joining-medicine-journey-high-reliability
October 19, 2022 - Study
Dental patient safety in the military health system: joining medicine in the journey to high reliability.
Citation Text:
Stahl JM, Mack K, Cebula S, et al. Dental Patient Safety in the Military Health System: Joining Medicine in the Journey to High Reliability. Mil Med. 2019. doi:1…
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psnet.ahrq.gov/issue/100000-lives-campaign-crystallizing-standards-care-hospitals
August 20, 2018 - Commentary
The 100,000 Lives Campaign: crystallizing standards of care for hospitals.
Citation Text:
Gosfield AG, Reinertsen JL. The 100,000 lives campaign: crystallizing standards of care for hospitals. Health Aff (Millwood). 2005;24(6):1560-70.
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psnet.ahrq.gov/issue/hospitals-often-ignore-policies-using-qualified-medical-interpreters
April 22, 2016 - Newspaper/Magazine Article
Hospitals often ignore policies on using qualified medical interpreters.
Citation Text:
Rice S. Language liabilities. To avoid errors, hospitals urged to use qualified interpreters for patients with limited English. Modern healthcare. 2014;44(35):16-8, 20.
Co…
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psnet.ahrq.gov/issue/motivational-influences-anaesthetists-use-practice-guidelines
April 18, 2011 - Study
Motivational influences on anaesthetists' use of practice guidelines.
Citation Text:
Phipps DL, Beatty PCW, Parker D, et al. Motivational influences on anaesthetists' use of practice guidelines. Br J Anaesth. 2009;102(6):768-74. doi:10.1093/bja/aep082.
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psnet.ahrq.gov/issue/geometric-probability-distribution-modeling-error-risk-during-prescription-dispensing
December 24, 2008 - Study
Geometric probability distribution for modeling of error risk during prescription dispensing.
Citation Text:
Carnahan BJ, Maghsoodloo S, Flynn EA, et al. Geometric probability distribution for modeling of error risk during prescription dispensing. Am J Health Syst Pharm. 2006;63(…
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psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-trade-offs
November 04, 2020 - Commentary
Scandal as a sentinel event—recognizing hidden cost–quality trade-offs.
Citation Text:
Bloche G. Scandal as a Sentinel Event--Recognizing Hidden Cost-Quality Trade-offs. N Engl J Med. 2016;374(11):1001-3. doi:10.1056/NEJMp1502629.
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psnet.ahrq.gov/issue/ethical-considerations-disclosure-when-medical-error-discovered-during-medicolegal-death
December 14, 2016 - Commentary
Ethical considerations on disclosure when medical error is discovered during medicolegal death investigation.
Citation Text:
Wolf DA, Drake SA, Snow FK. Ethical Considerations on Disclosure When Medical Error Is Discovered During Medicolegal Death Investigation. Am J Forensic …
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psnet.ahrq.gov/issue/outcomes-card-development-systems-based-practice-educational-tool
July 13, 2010 - Study
The outcomes card: development of a systems-based practice educational tool.
Citation Text:
Tomolo A, Caron A, Perz ML, et al. The outcomes card. J Gen Intern Med. 2005;20(8). doi:10.1111/j.1525-1497.2005.0168.x.
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psnet.ahrq.gov/issue/implementing-nurse-shadowing-program-first-year-medical-students-improve-interprofessional
January 15, 2025 - Commentary
Implementing a nurse-shadowing program for first-year medical students to improve interprofessional collaborations on health care teams.
Citation Text:
Jain A, Luo E, Yang J, et al. Implementing a nurse-shadowing program for first-year medical students to improve interprofessi…
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psnet.ahrq.gov/issue/retractions-medical-literature-how-many-patients-are-put-risk-flawed-research
August 31, 2011 - Study
Retractions in the medical literature: how many patients are put at risk by flawed research?
Citation Text:
Steen G. Retractions in the medical literature: how many patients are put at risk by flawed research? J Med Ethics. 2011;37(11):688-92. doi:10.1136/jme.2011.043133.
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psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - Impaired mobility from deconditioning increases the risk of falls, as well as preventing the patient
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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 2023 - The Dose Makes the Poison: Medication Error During
Procedural Sedation in the Pediatric Emergency
Department.
April 26, 2023
Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the
Pediatric Emergency Department. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/do…
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psnet.ahrq.gov/node/33608/psn-pdf
February 01, 2024 - Maternal Safety
January 31, 2024
Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/maternal-safety
Originally published in 2018 by researchers at the University of California, San Francisco. Updated in
February 2024 by Marla Shauer, PhD(c), MSN, CNM, Amy Nichols,…
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psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience
William S. Krimsky, MD | November 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [inter…
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psnet.ahrq.gov/node/60542/psn-pdf
May 27, 2020 - Life-Threatening Infant Overdose of Sodium Chloride
May 27, 2020
Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
The Case
An infant with trisomy 21 underwent repair of a…
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psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
February 26, 2025 - In Conversation With… J. Bryan Sexton, PhD, MA
August 1, 2013
Citation Text:
In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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