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  1. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. | PSNet

    psnet.ahrq.gov/issue/disruptions-surgical-flow-and-their-relationship-surgical-errors-exploratory-investigation
    August 26, 2011 - Study Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Citation Text: Wiegmann DA, Elbardissi AW, Dearani JA, et al. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;…

  2. Learning from incidents in healthcare: the journey, not the arrival, matters. | PSNet

    psnet.ahrq.gov/issue/learning-incidents-healthcare-journey-not-arrival-matters
    June 12, 2024 - Commentary Learning from incidents in healthcare: the journey, not the arrival, matters. Citation Text: Leistikow I, Mulder S, Vesseur J, et al. Learning from incidents in healthcare: the journey, not the arrival, matters. BMJ Qual Saf. 2017;26(3):252-256. doi:10.1136/bmjqs-2015-004853. …

  3. Adverse events during hospitalization: results of a patient survey. | PSNet

    psnet.ahrq.gov/issue/adverse-events-during-hospitalization-results-patient-survey
    December 29, 2014 - Study Adverse events during hospitalization: results of a patient survey. Citation Text: Fowler FJ, Epstein AM, Weingart SN, et al. Adverse events during hospitalization: results of a patient survey. Jt Comm J Qual Patient Saf. 2008;34(10):583-90. Copy Citation Format: Goog…

  4. Educating medical trainees on medication reconciliation: a systematic review. | PSNet

    psnet.ahrq.gov/issue/educating-medical-trainees-medication-reconciliation-systematic-review
    October 16, 2019 - Review Educating medical trainees on medication reconciliation: a systematic review. Citation Text: Ramjaun A, Sudarshan M, Patakfalvi L, et al. Educating medical trainees on medication reconciliation: a systematic review. BMC Med Educ. 2015;15:33. doi:10.1186/s12909-015-0306-5. Copy C…

  5. ProvenCare: quality improvement model for designing highly reliable care in cardiac surgery. | PSNet

    psnet.ahrq.gov/issue/provencare-quality-improvement-model-designing-highly-reliable-care-cardiac-surgery
    February 09, 2011 - Study ProvenCare: quality improvement model for designing highly reliable care in cardiac surgery. Citation Text: Berry SA, Doll MC, McKinley KE, et al. ProvenCare: quality improvement model for designing highly reliable care in cardiac surgery. Qual Saf Health Care. 2009;18(5):360-8. d…

  6. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. | PSNet

    psnet.ahrq.gov/issue/prescriber-barriers-and-enablers-minimising-potentially-inappropriate-medications-adults
    September 23, 2020 - Review Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. Citation Text: Anderson K, Stowasser D, Freeman C, et al. Prescriber barriers and enablers to minimising potentially inappropriate medication…

  7. Relationships among psychological safety, the principles of high reliability, and safety reporting intentions in pediatric nursing. | PSNet

    psnet.ahrq.gov/issue/relationships-among-psychological-safety-principles-high-reliability-and-safety-reporting
    September 16, 2015 - Study Relationships among psychological safety, the principles of high reliability, and safety reporting intentions in pediatric nursing. Citation Text: Pfeifer L, Vessey J, Cazzell M, et al. Relationships among psychological safety, the principles of high reliability, and safety reporti…

  8. SAFER Care: improving caregiver comprehension of discharge instructions. | PSNet

    psnet.ahrq.gov/issue/safer-care-improving-caregiver-comprehension-discharge-instructions
    October 26, 2022 - Study SAFER Care: improving caregiver comprehension of discharge instructions. Citation Text: Uong A, Philips K, Hametz P, et al. SAFER care: improving caregiver comprehension of discharge instructions. Pediatrics. 2021;147(4):e20200031. doi:10.1542/peds.2020-0031. Copy Citation Fo…

  9. Is there a "July phenomenon" in pediatric neurosurgery at teaching hospitals? | PSNet

    psnet.ahrq.gov/issue/there-july-phenomenon-pediatric-neurosurgery-teaching-hospitals
    May 23, 2018 - Study Is there a "July phenomenon" in pediatric neurosurgery at teaching hospitals? Citation Text: Smith ER, Butler WE, Barker FG. Is there a "July phenomenon" in pediatric neurosurgery at teaching hospitals? J Neurosurg. 2006;105(3 Suppl):169-76. Copy Citation Format: Go…

  10. Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients. | PSNet

    psnet.ahrq.gov/issue/assessment-safety-enhancement-hospital-medication-reconciliation-process-elderly-patients
    August 04, 2021 - Study Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients. Citation Text: Gizzi LA, Slain D, Hare JT, et al. Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients. Am J Geriatr Phar…

  11. ‘Ladder’-based safety culture assessments inversely predict safety outcomes. | PSNet

    psnet.ahrq.gov/issue/ladder-based-safety-culture-assessments-inversely-predict-safety-outcomes
    January 22, 2025 - Commentary ‘Ladder’-based safety culture assessments inversely predict safety outcomes. Citation Text: Boskeljon‐Horst L, Sillem S, Dekker SWA. ‘Ladder’‐based safety culture assessments inversely predict safety outcomes. J Contingencies Crisis Manag. 2022;31(3):372-391. doi:10.1111/1468-…

  12. Honest communication and social asymmetries inside a hospital: pitfalls for clinicians. | PSNet

    psnet.ahrq.gov/issue/honest-communication-and-social-asymmetries-inside-hospital-pitfalls-clinicians
    March 02, 2022 - Commentary Honest communication and social asymmetries inside a hospital: pitfalls for clinicians. Citation Text: Redelmeier DA, Etchells EE, Najeeb U. Honest communication and social asymmetries inside a hospital: pitfalls for clinicians. J Hosp Med. 2022;17(5):405-409. doi:10.1002/jhm.…

  13. Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians. | PSNet

    psnet.ahrq.gov/issue/causes-errors-electrocardiographic-diagnosis-atrial-fibrillation-physicians
    April 16, 2018 - Study Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians. Citation Text: Davidenko JM, Snyder LS. Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians. J Electrocardiol. 2007;40(5):450-6. Copy Citation …

  14. Cognitive errors detected in anaesthesiology: a literature review and pilot study. | PSNet

    psnet.ahrq.gov/issue/cognitive-errors-detected-anaesthesiology-literature-review-and-pilot-study
    November 21, 2012 - Study Cognitive errors detected in anaesthesiology: a literature review and pilot study. Citation Text: Stiegler MP, Neelankavil JP, Canales C, et al. Cognitive errors detected in anaesthesiology: a literature review and pilot study. Br J Anaesth. 2012;108(2):229-35. doi:10.1093/bja/ae…

  15. A simulation-based evaluation of methods to estimate the impact of an adverse event on hospital length of stay. | PSNet

    psnet.ahrq.gov/issue/simulation-based-evaluation-methods-estimate-impact-adverse-event-hospital-length-stay
    December 23, 2011 - Study A simulation-based evaluation of methods to estimate the impact of an adverse event on hospital length of stay. Citation Text: Samore MH, Shen S, Greene T, et al. A simulation-based evaluation of methods to estimate the impact of an adverse event on hospital length of stay. Med C…

  16. Effect of a rapid response team on the incidence of in-hospital mortality. | PSNet

    psnet.ahrq.gov/issue/effect-rapid-response-team-incidence-hospital-mortality
    March 15, 2023 - Study Effect of a rapid response team on the incidence of in-hospital mortality. Citation Text: Factora F, Maheshwari K, Khanna S, et al. Effect of a rapid response team on the incidence of in-hospital mortality. Anesth Analg. 2022;135(3):595-604. doi:10.1213/ane.0000000000006005. Copy…

  17. Rates and characteristics of paid malpractice claims among US physicians by specialty, 1992–2014. | PSNet

    psnet.ahrq.gov/issue/rates-and-characteristics-paid-malpractice-claims-among-us-physicians-specialty-1992-2014
    December 19, 2014 - Study Classic Rates and characteristics of paid malpractice claims among US physicians by specialty, 1992–2014. Citation Text: Schaffer A, Jena AB, Seabury SA, et al. Rates and Characteristics of Paid Malpractice Claims Among US Physicians by Specialty, 1992-201…

  18. Patient falls while under supervision: trends from incident reporting. | PSNet

    psnet.ahrq.gov/issue/patient-falls-while-under-supervision-trends-incident-reporting
    January 11, 2023 - Study Patient falls while under supervision: trends from incident reporting. Citation Text: Roberts M. Patient falls while under supervision: trends from incident reporting. Br J Nurs. 2023;32(11):508-513. doi:10.12968/bjon.2023.32.11.508. Copy Citation Format: DOI Google S…

  19. Creating a nurse-led culture to minimize horizontal violence in the acute care setting: a multi-interventional approach. | PSNet

    psnet.ahrq.gov/issue/creating-nurse-led-culture-minimize-horizontal-violence-acute-care-setting-multi
    July 05, 2017 - Commentary Creating a nurse-led culture to minimize horizontal violence in the acute care setting: a multi-interventional approach. Citation Text: Parker KM, Harrington A, Smith CM, et al. Creating a Nurse-Led Culture to Minimize Horizontal Violence in the Acute Care Setting: A Multi-Int…

  20. The detection, analysis, and significance of physician clustering in medical malpractice lawsuit payouts. | PSNet

    psnet.ahrq.gov/issue/detection-analysis-and-significance-physician-clustering-medical-malpractice-lawsuit-payouts
    June 22, 2022 - Study The detection, analysis, and significance of physician clustering in medical malpractice lawsuit payouts. Citation Text: Oshel RE, Levitt P. The Detection, Analysis, and Significance of Physician Clustering in Medical Malpractice Lawsuit Payouts. J Patient Saf. 2016;16(4):274-278. …
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