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  1. A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic. | PSNet

    psnet.ahrq.gov/issue/multi-site-assessment-inpatient-safety-event-rates-during-coronavirus-disease-2019-pandemic
    May 25, 2022 - Commentary A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic. Citation Text: Pollock BD, Dykhoff HJ, Breeher LE, et al. A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic. Mayo Clin Proc …

  2. Two fatal cases of accidental intrathecal vincristine administration: learning from death events. | PSNet

    psnet.ahrq.gov/issue/two-fatal-cases-accidental-intrathecal-vincristine-administration-learning-death-events
    March 24, 2021 - Commentary Two fatal cases of accidental intrathecal vincristine administration: learning from death events. Citation Text: Chotsampancharoen T, Sripornsawan P, Wongchanchailert M. Two fatal cases of accidental intrathecal vincristine administration: learning from death event. Chemothera…

  3. The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases. | PSNet

    psnet.ahrq.gov/issue/efficacy-medical-team-training-improved-team-performance-and-decreased-operating-room-delays
    October 06, 2016 - Study The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases. Citation Text: Wolf FA, Way LW, Stewart L. The efficacy of medical team training: improved team performance and decreased operating room delays…

  4. Improving the approach to defining, classifying, reporting and monitoring adverse events in seriously ill older adults: recommendations from a multi-stakeholder convening. | PSNet

    psnet.ahrq.gov/issue/improving-approach-defining-classifying-reporting-and-monitoring-adverse-events-seriously-ill
    July 29, 2020 - Commentary Improving the approach to defining, classifying, reporting and monitoring adverse events in seriously ill older adults: recommendations from a multi-stakeholder convening. Citation Text: Baim-Lance A, Ferreira KB, Cohen HJ, et al. Improving the approach to defining, classifyin…

  5. Analysis of adverse events associated with adult moderate procedural sedation outside the operating room. | PSNet

    psnet.ahrq.gov/issue/analysis-adverse-events-associated-adult-moderate-procedural-sedation-outside-operating-room
    August 13, 2014 - Study Analysis of adverse events associated with adult moderate procedural sedation outside the operating room. Citation Text: Karamnov S, Sarkisian N, Grammer R, et al. Analysis of Adverse Events Associated With Adult Moderate Procedural Sedation Outside the Operating Room. J Patient Sa…

  6. Impact of errors in paper-based and computerized diabetes management with decision support for hospitalized patients with type 2 diabetes. A post-hoc analysis of a before and after study. | PSNet

    psnet.ahrq.gov/issue/impact-errors-paper-based-and-computerized-diabetes-management-decision-support-hospitalized
    April 03, 2024 - Study Impact of errors in paper-based and computerized diabetes management with decision support for hospitalized patients with type 2 diabetes. A post-hoc analysis of a before and after study. Citation Text: Donsa K, Beck P, Höll B, et al. Impact of errors in paper-based and computerize…

  7. Job Aid: Practice Assessments and Surveys (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-practice-assessments.pdf
    June 02, 2025 - Job Aid: Practice Assessments and Surveys Primary Care Practice Facilitator Training Series 1 Job Aid: Practice Assessments and Surveys Overview Practice assessments and surveys are simple and non-threatening ways for a practice to gather information, generate ideas for improvements, and test and…

  8. Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery. | PSNet

    psnet.ahrq.gov/issue/reducing-burden-surgical-harm-systematic-review-interventions-used-reduce-adverse-events
    June 21, 2016 - Review Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery. Citation Text: Howell A-M, Panesar S, Burns EM, et al. Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse eve…

  9. Surgical safety and hospital volume across a wide range of interventions. | PSNet

    psnet.ahrq.gov/issue/surgical-safety-and-hospital-volume-across-wide-range-interventions
    April 04, 2011 - Study Surgical safety and hospital volume across a wide range of interventions. Citation Text: Eggli Y, Halfon P, Meylan D, et al. Surgical safety and hospital volume across a wide range of interventions. Med Care. 2010;48(11):962-71. doi:10.1097/MLR.0b013e3181eaf9f6. Copy Citation …

  10. Morning handover of on-call issues: opportunities for improvement. | PSNet

    psnet.ahrq.gov/issue/morning-handover-call-issues-opportunities-improvement
    September 26, 2012 - Study Morning handover of on-call issues: opportunities for improvement. Citation Text: Devlin MK, Kozij NK, Kiss A, et al. Morning handover of on-call issues: opportunities for improvement. JAMA Intern Med. 2014;174(9):1479-85. doi:10.1001/jamainternmed.2014.3033. Copy Citation Fo…

  11. Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. | PSNet

    psnet.ahrq.gov/issue/risk-adjusted-morbidity-teaching-hospitals-correlates-reported-levels-communication-and
    July 12, 2010 - Study Classic Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. Citation Text: Davenport DL…

  12. Identifying hospital-wide harm: a set of ICD-9–CM-coded conditions associated with increased cost, length of stay, and risk of mortality. | PSNet

    psnet.ahrq.gov/issue/identifying-hospital-wide-harm-set-icd-9-cm-coded-conditions-associated-increased-cost-length
    September 07, 2016 - Study Identifying hospital-wide harm: a set of ICD-9–CM-coded conditions associated with increased cost, length of stay, and risk of mortality. Citation Text: Bankowitz RA, Doyle B, Duan M, et al. Identifying hospital-wide harm: a set of ICD-9-CM-coded conditions associated with increase…

  13. Clinical diagnoses and autopsy findings: discrepancies in critically ill patients. | PSNet

    psnet.ahrq.gov/issue/clinical-diagnoses-and-autopsy-findings-discrepancies-critically-ill-patients
    March 09, 2022 - Study Clinical diagnoses and autopsy findings: discrepancies in critically ill patients. Citation Text: Tejerina E, Esteban A, Fernández-Segoviano P, et al. Clinical diagnoses and autopsy findings: discrepancies in critically ill patients*. Crit Care Med. 2012;40(3):842-6. doi:10.1097/…

  14. Office surgery incidents: what seven years of Florida data show us. | PSNet

    psnet.ahrq.gov/issue/office-surgery-incidents-what-seven-years-florida-data-show-us
    August 19, 2009 - Study Office surgery incidents: what seven years of Florida data show us. Citation Text: Coldiron BM, Healy C, Bene NI. Office surgery incidents: what seven years of Florida data show us. Dermatol Surg. 2008;34(3):285-91; discussion 291-2. doi:10.1111/j.1524-4725.2007.34060.x. Copy C…

  15. Medical errors during training: how do residents cope?: a descriptive study. | PSNet

    psnet.ahrq.gov/issue/medical-errors-during-training-how-do-residents-cope-descriptive-study
    October 13, 2021 - Study Medical errors during training: how do residents cope?: a descriptive study. Citation Text: Fatima S, Soria S, Esteban- Cruciani N. Medical errors during training: how do residents cope?: a descriptive study. BMC Med Educ. 2021;21(1):408. doi:10.1186/s12909-021-02850-1. Copy Cit…

  16. Comparing the variability of ingredient, strength, and dose form information from electronic prescriptions with RxNorm drug product descriptions. | PSNet

    psnet.ahrq.gov/issue/comparing-variability-ingredient-strength-and-dose-form-information-electronic-prescriptions
    March 20, 2024 - Study Comparing the variability of ingredient, strength, and dose form information from electronic prescriptions with RxNorm drug product descriptions. Citation Text: Lester CA, Flynn AJ, Marshall VD, et al. Comparing the variability of ingredient, strength, and dose form information fro…

  17. Appendix P. Evaluating and Selecting Hand Hygiene Products - Implementation Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-p.html
    May 01, 2017 - Appendix P. Evaluating and Selecting Hand Hygiene Products - Implementation Guide Slide 1: Appendix P. Evaluating and Selecting Hand Hygiene Products Timothy Landers, Ph.D., R.N., CNP, CIC Assistant Professor, The Ohio State University College of Nursing Slide 2: Disclosures Dr. Landers receives sala…

  18. Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency department. | PSNet

    psnet.ahrq.gov/issue/using-failure-mode-and-effect-analysis-identify-potential-failures-psychiatric-hospital
    June 22, 2017 - Study Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency department. Citation Text: Gur-Arieh S, Mendlovic S, Rozenblum R, et al. Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergen…

  19. Assessing patient safety in a pediatric telemedicine setting: a multi-methods study. | PSNet

    psnet.ahrq.gov/issue/assessing-patient-safety-pediatric-telemedicine-setting-multi-methods-study
    May 01, 2024 - Study Emerging Classic Assessing patient safety in a pediatric telemedicine setting: a multi-methods study. Citation Text: Haimi M, Brammli-Greenberg S, Baron-Epel O, et al. Assessing patient safety in a pediatric telemedicine setting: a multi-methods study. BMC…

  20. Surgical patient safety outcomes in critical access hospitals: how do they compare? | PSNet

    psnet.ahrq.gov/issue/surgical-patient-safety-outcomes-critical-access-hospitals-how-do-they-compare
    June 05, 2019 - Study Surgical patient safety outcomes in critical access hospitals: how do they compare? Citation Text: Natafgi N, Baloh J, Weigel P, et al. Surgical Patient Safety Outcomes in Critical Access Hospitals: How Do They Compare? J Rural Health. 2016;33(2):117-126. doi:10.1111/jrh.12176. C…
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