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  1. FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that accidental exposure to used patches can cause death. | PSNet

    psnet.ahrq.gov/issue/fda-requiring-color-changes-duragesic-fentanyl-pain-patches-aid-safety-emphasizing-accidental
    August 05, 2020 - Press Release/Announcement FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that accidental exposure to used patches can cause death. Citation Text: FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that…

  2. Expanding what we know about off-peak mortality in hospitals. | PSNet

    psnet.ahrq.gov/issue/expanding-what-we-know-about-peak-mortality-hospitals
    July 09, 2008 - Study Expanding what we know about off-peak mortality in hospitals. Citation Text: Hamilton P, Mathur S, Gemeinhardt G, et al. Expanding what we know about off-peak mortality in hospitals. J Nurs Adm. 2010;40(3):124-8. doi:10.1097/NNA.0b013e3181d0426e. Copy Citation Format: …

  3. Health care worker fatigue. | PSNet

    psnet.ahrq.gov/issue/health-care-worker-fatigue
    July 08, 2020 - Commentary Health care worker fatigue. Citation Text: Gardner LA, Dubeck D. Health Care Worker Fatigue. Am J Nurs. 2016;116(8):58-62. doi:10.1097/01.NAJ.0000490182.21432.85. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…

  4. Instituting a culture of professionalism: the establishment of a Center for Professionalism and Peer Support. | PSNet

    psnet.ahrq.gov/issue/instituting-culture-professionalism-establishment-center-professionalism-and-peer-support
    March 03, 2011 - Commentary Instituting a culture of professionalism: the establishment of a Center for Professionalism and Peer Support. Citation Text: Shapiro J, Whittemore A, Tsen LC. Instituting a culture of professionalism: the establishment of a center for professionalism and peer support. Jt Comm …

  5. ASHP Guidelines on Preventing Diversion of Controlled Substances. | PSNet

    psnet.ahrq.gov/issue/ashp-guidelines-preventing-diversion-controlled-substances
    June 15, 2022 - Organizational Policy/Guidelines ASHP Guidelines on Preventing Diversion of Controlled Substances. Citation Text: Clark J, Fera T, Fortier CR, et al. ASHP Guidelines on Preventing Diversion of Controlled Substances. Am J Health Syst Pharm. 2022;79(24):2279-2306. doi:10.1093/ajhp/zxac246.…

  6. What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings. | PSNet

    psnet.ahrq.gov/issue/what-would-you-ideally-do-if-there-were-no-targets-ethnographic-study-unintended-consequences
    July 27, 2011 - Study What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings. Citation Text: Allard J, Bleakley A. What would you ideally do if there were no targets? An ethnographic study of the unintended…

  7. Impact of organizational leadership on physician burnout and satisfaction. | PSNet

    psnet.ahrq.gov/issue/impact-organizational-leadership-physician-burnout-and-satisfaction
    June 28, 2010 - Study Impact of organizational leadership on physician burnout and satisfaction. Citation Text: Shanafelt TD, Gorringe G, Menaker R, et al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90(4):432-40. doi:10.1016/j.mayocp.2015.01.012. Co…

  8. Diagnostic errors in musculoskeletal oncology and possible mitigation strategies. | PSNet

    psnet.ahrq.gov/issue/diagnostic-errors-musculoskeletal-oncology-and-possible-mitigation-strategies
    May 01, 2013 - Commentary Diagnostic errors in musculoskeletal oncology and possible mitigation strategies. Citation Text: Flemming DJ, White C, Fox E, et al. Diagnostic errors in musculoskeletal oncology and possible mitigation strategies. Skeletal Radiol. 2023;52(3):493-503. doi:10.1007/s00256-022-04…

  9. A growth mindset approach to preparing trainees for medical error. | PSNet

    psnet.ahrq.gov/issue/growth-mindset-approach-preparing-trainees-medical-error
    August 19, 2020 - Commentary A growth mindset approach to preparing trainees for medical error. Citation Text: Klein J, Delany C, Fischer MD, et al. A growth mindset approach to preparing trainees for medical error. BMJ Qual Saf. 2017;26(9):771-774. doi:10.1136/bmjqs-2016-006416. Copy Citation Forma…

  10. Psychological safety and hierarchy in operating room debriefing: reflexive thematic analysis. | PSNet

    psnet.ahrq.gov/issue/psychological-safety-and-hierarchy-operating-room-debriefing-reflexive-thematic-analysis
    March 06, 2024 - Study Psychological safety and hierarchy in operating room debriefing: reflexive thematic analysis. Citation Text: McElroy C, Skegg E, Mudgway M, et al. Psychological safety and hierarchy in operating room debriefing: reflexive thematic analysis. J Surg Res. 2023;295:567-573. doi:10.1016…

  11. Surgeons' leadership style and team behavior in the hybrid operating room: prospective cohort study. | PSNet

    psnet.ahrq.gov/issue/surgeons-leadership-style-and-team-behavior-hybrid-operating-room-prospective-cohort-study
    August 31, 2022 - Study Surgeons' leadership style and team behavior in the hybrid operating room: prospective cohort study. Citation Text: Soenens G, Marchand B, Doyen B, et al. Surgeons' leadership style and team behavior in the hybrid operating room: prospective cohort study. Ann Surg. 2023;278(1):e5-e…

  12. Diagnostic disparities and strategies for enhancing diagnostic equity in hospital medicine. | PSNet

    psnet.ahrq.gov/issue/diagnostic-disparities-and-strategies-enhancing-diagnostic-equity-hospital-medicine
    April 12, 2023 - Commentary Diagnostic disparities and strategies for enhancing diagnostic equity in hospital medicine. Citation Text: Raffel KE, Gershanik EF, Ranji SR. Diagnostic disparities and strategies for enhancing diagnostic equity in hospital medicine. J Hosp Med. 2025;20(1):71-74. doi:10.1002/j…

  13. Using simulation to improve root cause analysis of adverse surgical outcomes. | PSNet

    psnet.ahrq.gov/issue/using-simulation-improve-root-cause-analysis-adverse-surgical-outcomes
    May 19, 2021 - Study Using simulation to improve root cause analysis of adverse surgical outcomes. Citation Text: Slakey DP, Simms ER, Rennie K, et al. Using simulation to improve root cause analysis of adverse surgical outcomes. Int J Qual Health Care. 2014;26(2):144-50. doi:10.1093/intqhc/mzu011. C…

  14. How improving practice relationships among clinicians and nonclinicians can improve quality in primary care. | PSNet

    psnet.ahrq.gov/issue/how-improving-practice-relationships-among-clinicians-and-nonclinicians-can-improve-quality
    December 18, 2013 - Study How improving practice relationships among clinicians and nonclinicians can improve quality in primary care. Citation Text: Lanham H, McDaniel RR, Crabtree B, et al. How improving practice relationships among clinicians and nonclinicians can improve quality in primary care. Jt Comm…

  15. Reliability of the assessment of preventable adverse drug events in daily clinical practice. | PSNet

    psnet.ahrq.gov/issue/reliability-assessment-preventable-adverse-drug-events-daily-clinical-practice
    March 04, 2011 - Study Reliability of the assessment of preventable adverse drug events in daily clinical practice. Citation Text: van Doormaal J, Mol PGM, van den Bemt PMLA, et al. Reliability of the assessment of preventable adverse drug events in daily clinical practice. Pharmacoepidemiol Drug Saf. …

  16. 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. …

  17. final Fibromyalgia CER protocol_3-31-14 (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/fibromyalgia_research-protocol.pdf
    April 03, 2014 - Typical treatments may be less effective31 or not feasible in this group of individuals and treatments … • Women and men • Individuals with coexisting mental health conditions • Individuals with high fibromyalgia … ) • Individuals with longer duration of fibromyalgia symptoms Question 2: What are the harms of … • Women and men • Individuals with coexisting mental health conditions • Individuals with high fibromyalgia … ) • Individuals with longer duration of fibromyalgia symptoms The subgroups in key questions

  18. AHRQ-Funded Research Improves Care of Patients and Their Engagement in Care | Digital Healthcare Research

    digital.ahrq.gov/2018-year-review/research-summary/improves-care-patients
    January 01, 2018 - Since usability is key to ensuring that health technology meets the needs of the individuals who use … s research concluded that patient-facing technology must be redesigned or enhanced to better allow individuals … with disabilities to fully engage with technology and demonstrated the importance of partnering with individuals

  19. Disparities-Quality-Improvement Executive (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/disparities-quality-improvement_executive.pdf
    August 01, 2012 - Inclusion and exclusion criteria Category Criteria Population Individuals receiving health care in … A minimum sample size of 50 individuals per study and intervention group or subgroup. … • The intervention was more effective in White and Black individuals relative to those of other or … speaking English as their primary language and individuals speaking a language other than English. … with limited health literacy (55.7 percent vs. 30 percent) but not among individuals with adequate

  20. Health IT Hazard Manager. | PSNet

    psnet.ahrq.gov/issue/health-it-hazard-manager
    August 01, 2012 - October 6, 2016 Findings and Lessons From the Improving Management of Individuals With … August 13, 2014 Findings and Lessons From the Improving Management of Individuals With
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