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  1. Inpatient Notes: human factors engineering and inpatient care—new ways to solve old problems. | PSNet

    psnet.ahrq.gov/issue/inpatient-notes-human-factors-engineering-and-inpatient-care-new-ways-solve-old-problems
    December 27, 2018 - Commentary Inpatient Notes: human factors engineering and inpatient care—new ways to solve old problems. Citation Text: Clack L, Sax H. Web Exclusives. Annals for Hospitalists Inpatient Notes - Human Factors Engineering and Inpatient Care-New Ways to Solve Old Problems. Ann Intern Med. 2…

  2. Addressing the elephant in the room: a shame resilience seminar for medical students. | PSNet

    psnet.ahrq.gov/issue/addressing-elephant-room-shame-resilience-seminar-medical-students
    June 07, 2023 - Commentary Addressing the elephant in the room: a shame resilience seminar for medical students. Citation Text: Bynum WE, Adams A, Edelman CE, et al. Addressing the Elephant in the Room: A Shame Resilience Seminar for Medical Students. Acad Med. 2019;94(8):1132-1136. doi:10.1097/ACM.0000…

  3. The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries. | PSNet

    psnet.ahrq.gov/issue/impact-resident-duty-hour-reform-hospital-readmission-rates-among-medicare-beneficiaries
    November 26, 2014 - Study The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries. Citation Text: Press MJ, Silber JH, Rosen AK, et al. The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries. J Gen Intern Med. 2011;26(4):…

  4. Effectiveness of interventions to improve patient handover in surgery: a systematic review. | PSNet

    psnet.ahrq.gov/issue/effectiveness-interventions-improve-patient-handover-surgery-systematic-review
    June 25, 2018 - Review Effectiveness of interventions to improve patient handover in surgery: a systematic review. Citation Text: Pucher PH, Johnston MJ, Aggarwal R, et al. Effectiveness of interventions to improve patient handover in surgery: A systematic review. Surgery. 2015;158(1):85-95. doi:10.1016…

  5. 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 …

  6. 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…

  7. 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…

  8. Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets. | PSNet

    psnet.ahrq.gov/issue/identification-and-safe-storage-look-alike-sound-alike-medicines-automated-dispensing
    June 23, 2009 - Study Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets. Citation Text: Ruutiainen HK, Kallio MM, Kuitunen SK. Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets. Eur J Hosp Pharm. 2021…

  9. ‘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-…

  10. 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.…

  11. Ambulatory patient safety. What we know and need to know. | PSNet

    psnet.ahrq.gov/issue/ambulatory-patient-safety-what-we-know-and-need-know
    May 27, 2015 - Study Ambulatory patient safety. What we know and need to know. Citation Text: Hammons T, Piland NF, Small SD, et al. Ambulatory Patient Safety. What we know and need to know. J Ambul Care Manage. 2013;26(1):63-82. doi:10.1097/00004479-200301000-00007. Copy Citation Format: …

  12. Analysis of Australian newspaper coverage of medication errors. | PSNet

    psnet.ahrq.gov/issue/analysis-australian-newspaper-coverage-medication-errors
    February 15, 2012 - Study Analysis of Australian newspaper coverage of medication errors. Citation Text: Hinchcliff R, Westbrook JI, Greenfield D, et al. Analysis of Australian newspaper coverage of medication errors. Int J Qual Health Care. 2012;24(1):1-8. doi:10.1093/intqhc/mzr067. Copy Citation For…

  13. Preventability of adverse drug events involving multiple drugs using publicly available clinical decision support tools. | PSNet

    psnet.ahrq.gov/issue/preventability-adverse-drug-events-involving-multiple-drugs-using-publicly-available-clinical
    December 21, 2017 - Study Preventability of adverse drug events involving multiple drugs using publicly available clinical decision support tools. Citation Text: Wright A, Feblowitz J, Phansalkar S, et al. Preventability of adverse drug events involving multiple drugs using publicly available clinical dec…

  14. Intravenous fluid prescribing errors in children: mixed methods analysis of critical incidents. | PSNet

    psnet.ahrq.gov/issue/intravenous-fluid-prescribing-errors-children-mixed-methods-analysis-critical-incidents
    June 14, 2023 - Study Intravenous fluid prescribing errors in children: mixed methods analysis of critical incidents. Citation Text: Conn RL, McVea S, Carrington A, et al. Intravenous fluid prescribing errors in children: Mixed methods analysis of critical incidents. PLoS One. 2017;12(10):e0186210. doi:…

  15. Patient safety climate among orthopaedic surgery residents. | PSNet

    psnet.ahrq.gov/issue/patient-safety-climate-among-orthopaedic-surgery-residents
    December 21, 2014 - Study Patient safety climate among orthopaedic surgery residents. Citation Text: Kadzielski J, McCormick F, Zurakowski D, et al. Patient safety climate among orthopaedic surgery residents. J Bone Joint Surg Am. 2011;93(11):e62. doi:10.2106/JBJS.J.01478. Copy Citation Format: …

  16. 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…

  17. 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…

  18. 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. …

  19. 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…

  20. Reducing anticoagulant medication adverse events and avoidable patient harm. | PSNet

    psnet.ahrq.gov/issue/reducing-anticoagulant-medication-adverse-events-and-avoidable-patient-harm
    May 19, 2021 - Study Reducing anticoagulant medication adverse events and avoidable patient harm. Citation Text: Jennings HR, Miller EC, Williams TS, et al. Reducing anticoagulant medication adverse vents and avoidable patient harm. Jt Comm J Qual Patient Saf. 2008;34(4):196-200. Copy Citation …
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