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  1. psnet.ahrq.gov/issue/medication-discrepancy-rates-and-sources-upon-nursing-home-intake-prospective-study
    February 12, 2020 - Study Medication discrepancy rates and sources upon nursing home intake: a prospective study. Citation Text: Patterson ME, Bollinger S, Coleman C, et al. Medication discrepancy rates and sources upon nursing home intake: a prospective study. Res Social Adm Pharm. 2022;18(5):2830-2836. do…
  2. psnet.ahrq.gov/issue/national-quality-program-achieves-improvements-safety-culture-and-reduction-preventable-harms
    November 02, 2022 - Study National quality program achieves improvements in safety culture and reduction in preventable harms in community hospitals. Citation Text: Frush K, Chamness C, Olson B, et al. National Quality Program Achieves Improvements in Safety Culture and Reduction in Preventable Harms in Com…
  3. psnet.ahrq.gov/issue/impact-safety-culture-quality-care-missed-care-and-nurse-staffing-patient-falls-multisource
    August 16, 2023 - Study The impact of safety culture, quality of care, missed care and nurse staffing on patient falls: a multisource association study. Citation Text: Alanazi FK, Lapkin S, Molloy L, et al. The impact of safety culture, quality of care, missed care and nurse staffing on patient falls: a m…
  4. psnet.ahrq.gov/issue/development-just-culture-assessment-tool-measuring-perceptions-health-care-professionals
    January 12, 2022 - Study Development of the just culture assessment tool: measuring the perceptions of health-care professionals in hospitals. Citation Text: Petschonek S, Burlison JD, Cross C, et al. Development of the just culture assessment tool: measuring the perceptions of health-care professionals i…
  5. psnet.ahrq.gov/issue/medicines-reconciliation-emergency-department-important-prescribing-discrepancies-between
    April 21, 2021 - Study Medicines reconciliation in the emergency department: important prescribing discrepancies between the shared medication record and patients' actual use of medication. Citation Text: Andersen TS, Gemmer MN, Sejberg HRC, et al. Medicines reconciliation in the emergency department: im…
  6. psnet.ahrq.gov/issue/teamwork-part-1-divided-we-fall-part-2-cursed-knowledge-building-culture-psychological-safety
    August 02, 2015 - Commentary Emerging Classic Teamwork- Part 1: Divided We Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem Problem. Citation Text: Rosenbaum L. Divided We Fall. N Engl J Med. 2019;380(7):684-688. doi:10…
  7. psnet.ahrq.gov/issue/barriers-and-facilitators-improving-patient-safety-learning-systems-systematic-review
    October 16, 2024 - Review Barriers and facilitators to improving patient safety learning systems: a systematic review of qualitative studies and meta-synthesis. Citation Text: Mahmoud HA, Thavorn K, Mulpuru S, et al. Barriers and facilitators to improving patient safety learning systems: a systematic revie…
  8. psnet.ahrq.gov/issue/perceptions-providing-safe-care-frail-older-people-home-qualitative-study-based-focus-group
    July 29, 2020 - Study Perceptions of providing safe care for frail older people at home: a qualitative study based on focus group interviews with home care staff. Citation Text: Silverglow A, Johansson L, Lidén E, et al. Perceptions of providing safe care for frail older people at home: a qualitative st…
  9. psnet.ahrq.gov/issue/never-events-and-quest-reduce-preventable-harm
    June 01, 2016 - Commentary "Never events" and the quest to reduce preventable harm. Citation Text: Austin M, Pronovost P. "Never events" and the quest to reduce preventable harm. Jt Comm J Qual Patient Saf. 2015;41(6):279-288. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 X…
  10. psnet.ahrq.gov/issue/risk-reduction-adverse-drug-events-through-sequential-implementation-patient-safety
    June 03, 2020 - Study Risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a children's hospital. Citation Text: Leonard MS, Cimino M, Shaha S, et al. Risk reduction for adverse drug events through sequential implementation of patient safety initiat…
  11. psnet.ahrq.gov/issue/evaluating-inpatient-mortality-new-electronic-review-process-gathers-information-front-line
    February 18, 2011 - Study Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers. Citation Text: Provenzano A, Rohan S, Trevejo E, et al. Evaluating inpatient mortality: a new electronic review process that gathers information from front-line provi…
  12. psnet.ahrq.gov/issue/adherence-surgical-care-improvement-project-measures-and-association-postoperative-infections
    November 25, 2020 - Study Classic Adherence to Surgical Care Improvement Project measures and the association with postoperative infections. Citation Text: Stulberg JJ, Delaney CP, Neuhauser D, et al. Adherence to surgical care improvement project measures and the association wit…
  13. psnet.ahrq.gov/innovation/novel-approach-engagement-team-training-high-technology-surgery-robotic-assisted-surgery
    June 21, 2023 - EMERGING INNOVATIONS A novel approach for engagement in team training in high-technology surgery: the robotic-assisted surgery olympics. Citation Text: Cohen TN, Anger JT, Kanji FF, et al. A novel approach for engagement in team training in high-technology surgery: the robotic-assisted surgery oly…
  14. psnet.ahrq.gov/issue/engaging-patients-and-informal-caregivers-improve-safety-and-facilitate-person-and-family
    March 08, 2023 - Study Engaging patients and informal caregivers to improve safety and facilitate person- and family-centered care during transitions from hospital to home: a qualitative descriptive study. Citation Text: Backman C, Cho-Young D. Engaging patients and informal caregivers to improve safety …
  15. psnet.ahrq.gov/issue/integrating-implementation-science-quality-and-patient-safety-improvement-learning
    January 24, 2024 - Study Integrating implementation science in a quality and patient safety improvement learning collaborative: essential ingredients and impact. Citation Text: Jeffs L, Bruno F, Zeng RL, et al. Integrating implementation science in a quality and patient safety improvement learning collabor…
  16. psnet.ahrq.gov/issue/impact-incorporating-pharmacy-claims-data-electronic-medication-reconciliation
    September 01, 2016 - Study Impact of incorporating pharmacy claims data into electronic medication reconciliation. Citation Text: Phansalkar S, Her QL, Tucker AD, et al. Impact of incorporating pharmacy claims data into electronic medication reconciliation. Am J Health Syst Pharm. 2015;72(3):212-7. doi:10.21…
  17. psnet.ahrq.gov/issue/hospital-readmission-risk-isolating-hospital-effects-patient-effects
    August 15, 2018 - Study Classic Hospital-readmission risk--isolating hospital effects from patient effects. Citation Text: Krumholz HM, Wang K, Lin Z, et al. Hospital-Readmission Risk - Isolating Hospital Effects from Patient Effects. N Engl J Med. 2017;377(11):1055-1064. doi:10.…
  18. psnet.ahrq.gov/issue/patient-education-prevent-falls-among-older-hospital-inpatients-randomized-controlled-trial
    February 14, 2017 - Study Patient education to prevent falls among older hospital inpatients: a randomized controlled trial. Citation Text: Haines TP, Hill A-M, Hill KD, et al. Patient education to prevent falls among older hospital inpatients: a randomized controlled trial. Arch Intern Med. 2011;171(6):516…
  19. psnet.ahrq.gov/issue/look-back-and-talk-openly-responding-and-communicating-about-risk-large-scale-error-pathology
    November 16, 2016 - Study Look back and talk openly: responding to and communicating about the risk of large-scale error in pathology diagnoses. Citation Text: Aldrich R, Finlayson P, Hill K, et al. Look back and talk openly: responding to and communicating about the risk of large-scale error in pathology d…
  20. psnet.ahrq.gov/issue/developing-open-disclosure-strategies-medical-error-using-simulation-final-year-medical
    September 29, 2018 - Study Developing open disclosure strategies to medical error using simulation in final-year medical students: linking mindset and experiential learning to lifelong reflective practice. Citation Text: Lane AS, Roberts C. Developing open disclosure strategies to medical error using simulat…