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psnet.ahrq.gov/issue/towards-unified-model-accident-causation-refining-and-validating-systems-thinking-safety
March 14, 2022 - Commentary
Towards a unified model of accident causation: refining and validating the systems thinking safety tenets.
Citation Text:
Salmon PM, Hulme A, Walker GH, et al. Towards a unified model of accident causation: refining and validating the systems thinking safety tenets. Ergonomics…
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psnet.ahrq.gov/issue/effect-fit-between-organizational-culture-and-structure-medication-errors-medical-group
June 30, 2009 - Study
The effect of the fit between organizational culture and structure on medication errors in medical group practices.
Citation Text:
Kaissi A, Kralewski J, Dowd B, et al. The effect of the fit between organizational culture and structure on medication errors in medical group practi…
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psnet.ahrq.gov/issue/improving-maternal-safety-scale-mentor-model-collaborative-improvement
March 31, 2021 - Study
Improving maternal safety at scale with the mentor model of collaborative improvement.
Citation Text:
Main EK, Dhurjati R, Cape V, et al. Improving Maternal Safety at Scale with the Mentor Model of Collaborative Improvement. Jt Comm J Qual Patient Saf. 2018;44(5):250-259. doi:10.10…
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psnet.ahrq.gov/issue/michigan-health-hospital-association-keystone-obstetrics-statewide-collaborative-perinatal
February 10, 2015 - Study
Michigan Health & Hospital Association Keystone Obstetrics: a statewide collaborative for perinatal patient safety in Michigan.
Citation Text:
Simpson KR, Knox GE, Martin M, et al. Michigan Health & Hospital Association Keystone Obstetrics: A Statewide Collaborative for Perinatal…
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psnet.ahrq.gov/issue/risk-management-and-patient-safety-artificial-intelligence-era-systematic-review
February 15, 2023 - Review
Risk management and patient safety in the artificial intelligence era: a systematic review.
Citation Text:
Ferrara M, Bertozzi G, Di Fazio N, et al. Risk management and patient safety in the artificial intelligence era: a systematic review. Healthcare (Basel). 2024;12(5):549. doi:…
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psnet.ahrq.gov/issue/improving-diagnosis-health-care
September 12, 2018 - Book/Report
Classic
Improving Diagnosis in Health Care.
Citation Text:
Improving Diagnosis in Health Care. Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2015. ISB…
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psnet.ahrq.gov/issue/towards-safer-transitions-curriculum-teach-and-assess-hospital-hospice-handoffs
March 20, 2024 - Commentary
Towards safer transitions: a curriculum to teach and assess hospital-to-hospice handoffs.
Citation Text:
Darrah NJ, O'Connor NR. Toward Safer Transitions: A Curriculum to Teach and Assess Hospital-to-Hospice Handoffs. J Pain Symptom Manage. 2016;51(6):959-962.e2. doi:10.1016/j…
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psnet.ahrq.gov/issue/electronic-health-records-ambulatory-care-national-survey-physicians
February 17, 2011 - Study
Electronic health records in ambulatory care- a national survey of physicians.
Citation Text:
DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care--a national survey of physicians. N Engl J Med. 2008;359(1):50-60. doi:10.1056/NEJMsa0802005.
Cop…
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psnet.ahrq.gov/issue/association-face-face-handoffs-and-outcomes-hospitalized-internal-medicine-patients
March 12, 2025 - Study
Association of face-to-face handoffs and outcomes of hospitalized internal medicine patients.
Citation Text:
Schouten WM, Burton C, Jones LKD, et al. Association of face-to-face handoffs and outcomes of hospitalized internal medicine patients. J Hosp Med. 2015;10(3):137-41. doi:10.…
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psnet.ahrq.gov/issue/framework-analysis-communication-errors-health-care
October 21, 2020 - Commentary
A framework for the analysis of communication errors in health care.
Citation Text:
Bender JA, Thiyagarajan S, Morrish W, et al. A framework for the analysis of communication errors in health care. J Patient Saf. 2025;21(2):69-81. doi:10.1097/pts.0000000000001303.
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psnet.ahrq.gov/issue/identifying-and-mapping-measures-medication-safety-during-transfer-care-digital-era-scoping
July 24, 2024 - Review
Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review.
Citation Text:
Leon C, Hogan H, Jani YH. Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literatur…
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psnet.ahrq.gov/issue/international-review-patient-safety-measures-radiotherapy-practice
May 22, 2019 - Review
An international review of patient safety measures in radiotherapy practice.
Citation Text:
Shafiq J, Barton M, Noble DJ, et al. An international review of patient safety measures in radiotherapy practice. Radiother Oncol. 2009;92(1):15-21. doi:10.1016/j.radonc.2009.03.007.
Co…
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psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation-stoelting-conference-2019-perioperative-deterioration
October 19, 2022 - Meeting/Conference Proceedings
The Anesthesia Patient Safety Foundation Stoelting Conference 2019: perioperative deterioration--early recognition, rapid intervention, and the end of failure-to-rescue.
Citation Text:
Lin D, Peden CJ, Langness SM, et al. The Anesthesia Patient Safety Found…
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psnet.ahrq.gov/issue/ten-years-incident-reports-hospital-cardiac-arrest-are-they-useful-improvements
January 26, 2022 - Study
Ten years of incident reports on in-hospital cardiac arrest - Are they useful for improvements?
Citation Text:
Djärv T. Ten years of incident reports on in-hospital cardiac arrest – Are they useful for improvements? Resusc Plus. 2023;17:100525. doi:10.1016/j.resplu.2023.100525.
C…
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psnet.ahrq.gov/issue/veterans-affairs-shift-change-physician-physician-handoff-project
April 30, 2014 - Study
The Veterans Affairs shift change physician-to-physician handoff project.
Citation Text:
Anderson J, Shroff D, Curtis A, et al. The Veterans Affairs shift change physician-to-physician handoff project. Jt Comm J Qual Patient Saf. 2010;36(2):62-71.
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psnet.ahrq.gov/issue/prospective-memory-icu-effect-visual-cues-task-execution-representative-simulation
April 24, 2018 - Study
Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation.
Citation Text:
Grundgeiger T, Sanderson PM, Orihuela B, et al. Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. Ergo…
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psnet.ahrq.gov/issue/comparing-safety-climate-naval-aviation-and-hospitals-implications-improving-patient-safety
October 14, 2009 - Study
Comparing safety climate in naval aviation and hospitals: implications for improving patient safety.
Citation Text:
Singer SJ, Rosen AK, Zhao S, et al. Comparing safety climate in naval aviation and hospitals: implications for improving patient safety. Health Care Manag Rev. 2010…
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psnet.ahrq.gov/issue/learning-mistakes-and-near-mistakes-using-root-cause-analysis-risk-management-tool
June 19, 2024 - Commentary
Learning from mistakes and near mistakes: using root cause analysis as a risk management tool.
Citation Text:
Cerniglia-Lowensen J. Learning From Mistakes and Near Mistakes: Using Root Cause Analysis as a Risk Management Tool. J Radiol Nurs. 2015;34(1). doi:10.1016/j.jradnu.20…
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psnet.ahrq.gov/issue/using-computerized-sign-out-system-improve-physician-nurse-communication
September 28, 2016 - Study
Using a computerized sign-out system to improve physician–nurse communication.
Citation Text:
Sidlow R, Katz-Sidlow RJ. Using a computerized sign-out system to improve physician-nurse communication. Jt Comm J Qual Patient Saf. 2006;32(1):32-36.
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psnet.ahrq.gov/node/73515/psn-pdf
August 01, 2022 - noting
the clear link between nursing home staffing ratios and resident outcomes.2
Description of the Innovative