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  1. Medicare payment for selected adverse events: building the business case for investing in patient safety. | PSNet

    psnet.ahrq.gov/issue/medicare-payment-selected-adverse-events-building-business-case-investing-patient-safety
    September 18, 2009 - Study Medicare payment for selected adverse events: building the business case for investing in patient safety. Citation Text: Zhan C, Friedman B, Mosso A, et al. Medicare payment for selected adverse events: building the business case for investing in patient safety. Health Aff (Millw…

  2. Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge. | PSNet

    psnet.ahrq.gov/issue/medication-reconciliation-accuracy-and-patient-understanding-intended-medication-changes
    July 29, 2020 - Study Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge. Citation Text: Ziaeian B, Araujo KLB, Van Ness PH, et al. Medication reconciliation accuracy and patient understanding of intended medication changes on hospital disch…

  3. Development and implementation of a suicide prevention checklist to create a safe environment. | PSNet

    psnet.ahrq.gov/issue/development-and-implementation-suicide-prevention-checklist-create-safe-environment
    August 04, 2021 - Study Development and implementation of a suicide prevention checklist to create a safe environment. Citation Text: Frost DA, Snydeman CK, Lantieri MJ, et al. Development and Implementation of a Suicide Prevention Checklist to Create a Safe Environment. Psychosomatics. 2019;61(2):154-160…

  4. Content analysis of nurses' reflections on medication errors in a regional hospital. | PSNet

    psnet.ahrq.gov/issue/content-analysis-nurses-reflections-medication-errors-regional-hospital
    December 23, 2020 - Study Content analysis of nurses' reflections on medication errors in a regional hospital. Citation Text: Issacs AN, RAYMOND A, KENT B. Content analysis of nurses’ reflections on medication errors in a regional hospital. Contemp Nurse. 2023;59(3):202-213. doi:10.1080/10376178.2023.222043…

  5. A study of innovative patient safety education. | PSNet

    psnet.ahrq.gov/issue/study-innovative-patient-safety-education
    April 28, 2021 - Study A study of innovative patient safety education. Citation Text: Smith SD, Henn P, Gaffney R, et al. A study of innovative patient safety education. Clin Teach. 2012;9(1):37-40. doi:10.1111/j.1743-498X.2011.00484.x. Copy Citation Format: DOI Google Scholar PubMed BibT…

  6. The Top Six: standardized safety practices in U.S. Army Medical Department treatment facilities worldwide. | PSNet

    psnet.ahrq.gov/issue/top-six-standardized-safety-practices-us-army-medical-department-treatment-facilities
    March 18, 2020 - Study The Top Six: standardized safety practices in U.S. Army Medical Department treatment facilities worldwide. Citation Text: Hartstein B, Munante M, Toor PA. The Top Six: Standardized safety practices in U.S. Army Medical Department treatment facilities worldwide. NEJM Catal Innov Car…

  7. Postoperative sepsis in the United States. | PSNet

    psnet.ahrq.gov/issue/postoperative-sepsis-united-states
    January 12, 2022 - Study Postoperative sepsis in the United States. Citation Text: Vogel TR, Dombrovskiy VY, Carson JL, et al. Postoperative sepsis in the United States. Ann Surg. 2010;252(6):1065-71. doi:10.1097/SLA.0b013e3181dcf36e. Copy Citation Format: DOI Google Scholar PubMed BibTeX E…

  8. 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…

  9. 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…

  10. 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…

  11. Resident-faculty overnight discrepancy rates as a function of number of consecutive nights during a week of night float. | PSNet

    psnet.ahrq.gov/issue/resident-faculty-overnight-discrepancy-rates-function-number-consecutive-nights-during-week
    November 16, 2022 - Study Resident-faculty overnight discrepancy rates as a function of number of consecutive nights during a week of night float. Citation Text: Peterson C, Moore M, Sarwani N, et al. Resident-faculty overnight discrepancy rates as a function of number of consecutive nights during a week of…

  12. 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…

  13. 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 …

  14. 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…

  15. 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: …

  16. 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…

  17. Accidental deaths, saved lives, and improved quality. | PSNet

    psnet.ahrq.gov/issue/accidental-deaths-saved-lives-and-improved-quality
    February 04, 2015 - Commentary Classic Accidental deaths, saved lives, and improved quality. Citation Text: Brennan TA, Gawande AA, Thomas EJ, et al. Accidental Deaths, Saved Lives, and Improved Quality. New England Journal of Medicine. 2005;353(13). doi:10.1056/nejmsb051157. C…

  18. 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…

  19. 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 …

  20. Important factors for effective patient safety governance auditing: a questionnaire survey. | PSNet

    psnet.ahrq.gov/issue/important-factors-effective-patient-safety-governance-auditing-questionnaire-survey
    December 04, 2015 - Study Important factors for effective patient safety governance auditing: a questionnaire survey. Citation Text: van Gelderen SC, Zegers M, Robben PB, et al. Important factors for effective patient safety governance auditing: a questionnaire survey. BMC Health Serv Res. 2018;18(1):798. d…
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