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  1. Morbidity and mortality caused by noncompliance with California hospital licensure: immediate jeopardies in California hospitals, 2007-2017. | PSNet

    psnet.ahrq.gov/issue/morbidity-and-mortality-caused-noncompliance-california-hospital-licensure-immediate
    May 19, 2021 - Study Morbidity and mortality caused by noncompliance with California hospital licensure: immediate jeopardies in California hospitals, 2007-2017. Citation Text: Zheng MY, Lui H, Patino G, et al. Morbidity and mortality caused by noncompliance with California hospital licensure: immediat…

  2. Good people who try their best can have problems: recognition of human factors and how to minimise error. | PSNet

    psnet.ahrq.gov/issue/good-people-who-try-their-best-can-have-problems-recognition-human-factors-and-how-minimise
    October 29, 2017 - Review Good people who try their best can have problems: recognition of human factors and how to minimise error. Citation Text: Brennan PA, Mitchell DA, Holmes S, et al. Good people who try their best can have problems: recognition of human factors and how to minimise error. Br J Oral Ma…

  3. Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids. | PSNet

    psnet.ahrq.gov/issue/identifying-systems-failures-pathway-catastrophic-event-analysis-national-incident-report
    January 22, 2014 - Study Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids. Citation Text: Franklin BD, Panesar S, Vincent CA, et al. Identifying systems failures in the pathway to a catastrophic event: an analysis …

  4. The Healthcare Complaints Analysis Tool: development and reliability testing of a method for service monitoring and organisational learning. | PSNet

    psnet.ahrq.gov/issue/healthcare-complaints-analysis-tool-development-and-reliability-testing-method-service
    November 29, 2023 - Study The Healthcare Complaints Analysis Tool: development and reliability testing of a method for service monitoring and organisational learning. Citation Text: Gillespie A, Reader TW. The Healthcare Complaints Analysis Tool: development and reliability testing of a method for service m…

  5. Serious experience events: applying patient safety concepts to improve patient experience. | PSNet

    psnet.ahrq.gov/issue/serious-experience-events-applying-patient-safety-concepts-improve-patient-experience
    August 04, 2021 - Commentary Serious experience events: applying patient safety concepts to improve patient experience. Citation Text: Donnelly LF, Uhlhorn E, Bargmann-Losche J, et al. Serious experience events: applying patient safety concepts to improve patient experience. J Patient Exp. 2022;9:23743735…

  6. Whistleblowing over patient safety and care quality: a review of the literature. | PSNet

    psnet.ahrq.gov/issue/whistleblowing-over-patient-safety-and-care-quality-review-literature
    April 08, 2019 - Review Emerging Classic Whistleblowing over patient safety and care quality: a review of the literature. Citation Text: Blenkinsopp J, Snowden N, Mannion R, et al. Whistleblowing over patient safety and care quality: a review of the literature. J Health Org Mana…

  7. Missed nursing care in emergency departments: a scoping review. | PSNet

    psnet.ahrq.gov/issue/missed-nursing-care-emergency-departments-scoping-review
    November 03, 2021 - Review Missed nursing care in emergency departments: a scoping review. Citation Text: Duhalde H, Bjuresäter K, Karlsson I, et al. Missed nursing care in emergency departments: a scoping review. Int Emerg Nurs. 2023;69:101296. doi:10.1016/j.ienj.2023.101296. Copy Citation Format: …

  8. How event reporting by US hospitals has changed from 2005 to 2009. | PSNet

    psnet.ahrq.gov/issue/how-event-reporting-us-hospitals-has-changed-2005-2009
    April 21, 2010 - Study How event reporting by US hospitals has changed from 2005 to 2009. Citation Text: Farley DO, Haviland AM, Haas A, et al. How event reporting by US hospitals has changed from 2005 to 2009. BMJ Qual Saf. 2011;21(1). doi:10.1136/bmjqs-2011-000114. Copy Citation Format: D…

  9. Quality of medication use in primary care—mapping the problem, working to a solution: a systematic review of the literature. | PSNet

    psnet.ahrq.gov/issue/quality-medication-use-primary-care-mapping-problem-working-solution-systematic-review
    February 23, 2011 - Review Quality of medication use in primary care—mapping the problem, working to a solution: a systematic review of the literature. Citation Text: Garfield S, Barber N, Walley P, et al. Quality of medication use in primary care--mapping the problem, working to a solution: a systematic …

  10. Computerized provider order entry adoption: implications for clinical workflow. | PSNet

    psnet.ahrq.gov/issue/computerized-provider-order-entry-adoption-implications-clinical-workflow
    May 27, 2011 - Study Computerized provider order entry adoption: implications for clinical workflow. Citation Text: Campbell EM, Guappone KP, Sittig DF, et al. Computerized provider order entry adoption: implications for clinical workflow. J Gen Intern Med. 2009;24(1):21-6. doi:10.1007/s11606-008-085…

  11. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2011. | PSNet

    psnet.ahrq.gov/issue/ashp-national-survey-pharmacy-practice-hospital-settings-dispensing-and-administration-2011
    September 30, 2020 - Study ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2011. Citation Text: Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration—2011. American Journal of H…

  12. Exploring relationships between hospital patient safety culture and adverse events. | PSNet

    psnet.ahrq.gov/issue/exploring-relationships-between-hospital-patient-safety-culture-and-adverse-events
    August 27, 2012 - Study Exploring relationships between hospital patient safety culture and adverse events. Citation Text: Mardon RE, Khanna K, Sorra J, et al. Exploring relationships between hospital patient safety culture and adverse events. J Patient Saf. 2010;6(4):226-32. doi:10.1097/PTS.0b013e3181fd1…

  13. How dangerous is a day in hospital?: A model of adverse events and length of stay for medical inpatients. | PSNet

    psnet.ahrq.gov/issue/how-dangerous-day-hospital-model-adverse-events-and-length-stay-medical-inpatients
    February 09, 2012 - Study Classic How dangerous is a day in hospital?: A model of adverse events and length of stay for medical inpatients. Citation Text: Hauck K, Zhao X. How dangerous is a day in hospital? A model of adverse events and length of stay for medical inpatients. Med…

  14. How does context affect interventions to improve patient safety? An assessment of evidence from studies of five patient safety practices and proposals for research. | PSNet

    psnet.ahrq.gov/issue/how-does-context-affect-interventions-improve-patient-safety-assessment-evidence-studies-five
    September 20, 2011 - Review How does context affect interventions to improve patient safety? An assessment of evidence from studies of five patient safety practices and proposals for research. Citation Text: Ovretveit JC, Shekelle PG, Dy SM, et al. How does context affect interventions to improve patient s…

  15. Challenging authority during a life-threatening crisis: the effect of operating theatre hierarchy. | PSNet

    psnet.ahrq.gov/issue/challenging-authority-during-life-threatening-crisis-effect-operating-theatre-hierarchy
    December 02, 2015 - Study Challenging authority during a life-threatening crisis: the effect of operating theatre hierarchy. Citation Text: Sydor DT, Bould MD, Naik VN, et al. Challenging authority during a life-threatening crisis: the effect of operating theatre hierarchy. Br J Anaesth. 2013;110(3):463-7…

  16. Factors associated with neuroradiologic diagnostic errors at a large tertiary-care academic medical center: a case-control study. | PSNet

    psnet.ahrq.gov/issue/factors-associated-neuroradiologic-diagnostic-errors-large-tertiary-care-academic-medical
    August 17, 2022 - Study Factors associated with neuroradiologic diagnostic errors at a large tertiary-care academic medical center: a case-control study. Citation Text: Ivanovic V, Broadhead K, Beck R, et al. Factors associated with neuroradiologic diagnostic errors at a large tertiary-care academic medic…

  17. A retrospective analysis demonstrates that a failure to document key comorbid diseases in the anesthesia preoperative evaluation associates with increased length of stay and mortality. | PSNet

    psnet.ahrq.gov/issue/retrospective-analysis-demonstrates-failure-document-key-comorbid-diseases-anesthesia
    May 26, 2021 - Study A retrospective analysis demonstrates that a failure to document key comorbid diseases in the anesthesia preoperative evaluation associates with increased length of stay and mortality. Citation Text: Hofer IS, Cheng D, Grogan T. A retrospective analysis demonstrates that a failure …

  18. Communication failure in the operating room. | PSNet

    psnet.ahrq.gov/issue/communication-failure-operating-room
    February 25, 2009 - Study Communication failure in the operating room. Citation Text: Halverson AL, Casey JT, Andersson J, et al. Communication failure in the operating room. Surgery. 2011;149(3):305-310. doi:10.1016/j.surg.2010.07.051. Copy Citation Format: DOI Google Scholar PubMed BibTeX …

  19. Safety as a criterion for quality: The Critical Nursing Situation Index in paediatric critical care, an observational study. | PSNet

    psnet.ahrq.gov/issue/safety-criterion-quality-critical-nursing-situation-index-paediatric-critical-care
    March 01, 2011 - Study Safety as a criterion for quality: The Critical Nursing Situation Index in paediatric critical care, an observational study. Citation Text: de Neef M, Bos AP, Tol D. Safety as a criterion for quality: the critical nursing situation index in paediatric critical care, an observatio…

  20. The state of health, burnout, healthy behaviors, workplace wellness support, and concerns of medication errors in pharmacists during the COVID-19 pandemic. | PSNet

    psnet.ahrq.gov/issue/state-health-burnout-healthy-behaviors-workplace-wellness-support-and-concerns-medication
    July 14, 2021 - Study The state of health, burnout, healthy behaviors, workplace wellness support, and concerns of medication errors in pharmacists during the COVID-19 pandemic. Citation Text: Melnyk BM, Hsieh AP, Tan A, et al. The state of health, burnout, healthy behaviors, workplace wellness support,…
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