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  1. Surgical specimen management: a descriptive study of 648 adverse events and near misses. | PSNet

    psnet.ahrq.gov/issue/surgical-specimen-management-descriptive-study-648-adverse-events-and-near-misses
    December 22, 2021 - Study Surgical specimen management: a descriptive study of 648 adverse events and near misses. Citation Text: Steelman VM, Williams TL, Szekendi MK, et al. Surgical specimen management: a descriptive study of 648 adverse events and near misses. Arch Pathol Lab Med. 2016;140(12):1390-1396…

  2. A review of medication errors and the second victim in pediatric pharmacy. | PSNet

    psnet.ahrq.gov/issue/review-medication-errors-and-second-victim-pediatric-pharmacy
    January 27, 2019 - Review A review of medication errors and the second victim in pediatric pharmacy. Citation Text: Bredenkamp K, Raschka MJ, Holmes A. A review of medication errors and the second victim in pediatric pharmacy. J Pediatr Pharmacol Ther. 2024;29(2):100-106. doi:10.5863/1551-6776-29.2.100. …

  3. Association between operative autonomy of surgical residents and patient outcomes. | PSNet

    psnet.ahrq.gov/issue/association-between-operative-autonomy-surgical-residents-and-patient-outcomes
    September 09, 2020 - Study Association between operative autonomy of surgical residents and patient outcomes. Citation Text: Oliver JB, Kunac A, McFarlane JL, et al. Association between operative autonomy of surgical residents and patient outcomes. JAMA Surg. 2022;157(3):211-219. doi:10.1001/jamasurg.2021.64…

  4. A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales. | PSNet

    psnet.ahrq.gov/issue/mixed-methods-analysis-patient-safety-incidents-involving-opioid-substitution-treatment
    August 25, 2021 - Study A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales. Citation Text: Gibson R, MacLeod N, Donaldson LJ, et al. A mixed‐methods analysis of patient safety incidents i…

  5. A multilevel analysis of U.S. hospital patient safety culture relationships with perceptions of voluntary event reporting. | PSNet

    psnet.ahrq.gov/issue/multilevel-analysis-us-hospital-patient-safety-culture-relationships-perceptions-voluntary
    December 21, 2016 - Study Classic A multilevel analysis of U.S. hospital patient safety culture relationships with perceptions of voluntary event reporting. Citation Text: Burlison JD, Quillivan RR, Kath LM, et al. A Multilevel Analysis of U.S. Hospital Patient Safety Culture Relat…

  6. Development of the just culture assessment tool: measuring the perceptions of health-care professionals in hospitals. | PSNet

    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…

  7. Safety competency: exploring the impact of environmental and personal factors on the nurse's ability to deliver safe care. | PSNet

    psnet.ahrq.gov/issue/safety-competency-exploring-impact-environmental-and-personal-factors-nurses-ability-deliver
    September 14, 2022 - Study Safety competency: exploring the impact of environmental and personal factors on the nurse's ability to deliver safe care. Citation Text: Dillon-Bleich K, Dolansky MA, Burant CJ, et al. Safety competency: exploring the impact of environmental and personal factors on the nurse's abi…

  8. Computerized order entry with limited decision support to prevent prescription errors in a PICU. | PSNet

    psnet.ahrq.gov/issue/computerized-order-entry-limited-decision-support-prevent-prescription-errors-picu
    January 31, 2018 - Study Computerized order entry with limited decision support to prevent prescription errors in a PICU. Citation Text: Kadmon G, Bron-Harlev E, Nahum E, et al. Computerized order entry with limited decision support to prevent prescription errors in a PICU. Pediatrics. 2009;124(3):935-94…

  9. Cost-benefit analysis of a medical emergency team in a children's hospital. | PSNet

    psnet.ahrq.gov/issue/cost-benefit-analysis-medical-emergency-team-childrens-hospital
    November 06, 2015 - Study Cost-benefit analysis of a medical emergency team in a children's hospital. Citation Text: Bonafide CP, Localio R, Song L, et al. Cost-benefit analysis of a medical emergency team in a children's hospital. Pediatrics. 2014;134(2):235-41. doi:10.1542/peds.2014-0140. Copy Citation …

  10. Accuracy of a proprietary large language model in labeling obstetric incident reports. | PSNet

    psnet.ahrq.gov/issue/accuracy-proprietary-large-language-model-labeling-obstetric-incident-reports
    September 23, 2020 - Study Accuracy of a proprietary large language model in labeling obstetric incident reports. Citation Text: Johnson J, Brown C, Lee GM, et al. Accuracy of a proprietary large language model in labeling obstetric incident reports. Jt Comm J Qual Patient Saf. 2024;50(12):877-881. doi:10.10…

  11. Bridging leadership roles in quality and patient safety: experience of 6 US academic medical centers. | PSNet

    psnet.ahrq.gov/issue/bridging-leadership-roles-quality-and-patient-safety-experience-6-us-academic-medical-centers
    September 04, 2016 - Study Bridging leadership roles in quality and patient safety: experience of 6 US academic medical centers. Citation Text: Myers JS, Tess A, McKinney K, et al. Bridging Leadership Roles in Quality and Patient Safety: Experience of 6 US Academic Medical Centers. J Grad Med Educ. 2017;9(1)…

  12. Outside case review of surgical pathology for referred patients: the impact on patient care. | PSNet

    psnet.ahrq.gov/issue/outside-case-review-surgical-pathology-referred-patients-impact-patient-care
    July 13, 2016 - Study Outside case review of surgical pathology for referred patients: the impact on patient care. Citation Text: Swapp RE, Aubry MC, Salomão DR, et al. Outside case review of surgical pathology for referred patients: the impact on patient care. Arch Pathol Lab Med. 2013;137(2):233-40. …

  13. Using a pediatric trigger tool to estimate total harm burden hospital-acquired conditions represent. | PSNet

    psnet.ahrq.gov/issue/using-pediatric-trigger-tool-estimate-total-harm-burden-hospital-acquired-conditions
    July 03, 2016 - Study Using a pediatric trigger tool to estimate total harm burden hospital-acquired conditions represent. Citation Text: Stockwell DC, Landrigan CP, Schuster MA, et al. Using a Pediatric Trigger Tool to Estimate Total Harm Burden Hospital-acquired Conditions Represent. Pediatr Qual Saf.…

  14. The incidence and nature of in-hospital adverse events: a systematic review. | PSNet

    psnet.ahrq.gov/issue/incidence-and-nature-hospital-adverse-events-systematic-review
    March 24, 2011 - Review The incidence and nature of in-hospital adverse events: a systematic review. Citation Text: de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17(3):216-223. doi:10.1136/qshc.20…

  15. 'I think we should just listen and get out': a qualitative exploration of views and experiences of Patient Safety Walkrounds. | PSNet

    psnet.ahrq.gov/issue/i-think-we-should-just-listen-and-get-out-qualitative-exploration-views-and-experiences
    June 22, 2022 - Study 'I think we should just listen and get out': a qualitative exploration of views and experiences of Patient Safety Walkrounds. Citation Text: Rotteau L, Shojania KG, Webster F. ‘I think we should just listen and get out’: a qualitative exploration of views and experiences of Patient…

  16. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. | PSNet

    psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and-attentional-failures
    February 02, 2011 - Study Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. Citation Text: Barger LK, Ayas N, Cade BE, et al. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. PLoS Med. 2006;3(12):e487. Copy Cita…

  17. Cost and workforce implications of subjecting all physicians to aviation industry work-hour restrictions.   | PSNet

    psnet.ahrq.gov/issue/cost-and-workforce-implications-subjecting-all-physicians-aviation-industry-work-hour
    January 02, 2017 - Study Cost and workforce implications of subjecting all physicians to aviation industry work-hour restrictions.   Citation Text: Payette M, Chatterjee A, Weeks WB. Cost and workforce implications of subjecting all physicians to aviation industry work-hour restrictions. Am J Surg. 2009;…

  18. Randomized trial of reducing ambulatory malpractice and safety risk: results of the Massachusetts PROMISES Project. | PSNet

    psnet.ahrq.gov/issue/randomized-trial-reducing-ambulatory-malpractice-and-safety-risk-results-massachusetts
    February 25, 2015 - Study Randomized trial of reducing ambulatory malpractice and safety risk: results of the Massachusetts PROMISES Project. Citation Text: Schiff G, Nieva HR, Griswold P, et al. Randomized Trial of Reducing Ambulatory Malpractice and Safety Risk: Results of the Massachusetts PROMISES Proje…

  19. Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors. | PSNet

    psnet.ahrq.gov/issue/outpatient-cpoe-orders-discontinued-due-erroneous-entry-prospective-survey-prescribers
    October 13, 2018 - Study Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors. Citation Text: Hickman T-TT, Quist AJL, Salazar A, et al. Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' expla…

  20. Analysis of variations in the display of drug names in computerized prescriber-order-entry systems. | PSNet

    psnet.ahrq.gov/issue/analysis-variations-display-drug-names-computerized-prescriber-order-entry-systems
    October 13, 2018 - Study Analysis of variations in the display of drug names in computerized prescriber-order-entry systems. Citation Text: Quist AJL, Hickman T-TT, Amato MG, et al. Analysis of variations in the display of drug names in computerized prescriber-order-entry systems. American Journal of Healt…
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