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  1. Establishing a multidisciplinary taskforce to improve anticoagulation safety at a large health system. | PSNet

    psnet.ahrq.gov/issue/establishing-multidisciplinary-taskforce-improve-anticoagulation-safety-large-health-system
    July 08, 2020 - Commentary Establishing a multidisciplinary taskforce to improve anticoagulation safety at a large health system. Citation Text: Attia E, Fuentes A, Vassallo M, et al. Establishing a multidisciplinary taskforce to improve anticoagulation safety at a large health system. Am J Health Syst …

  2. Hospital quality and patient safety competencies: development, description, and recommendations for use. | PSNet

    psnet.ahrq.gov/issue/hospital-quality-and-patient-safety-competencies-development-description-and-recommendations
    January 10, 2018 - Commentary Hospital quality and patient safety competencies: development, description, and recommendations for use. Citation Text: O'Leary KJ, Afsar-Manesh N, Budnitz T, et al. Hospital quality and patient safety competencies: Development, description, and recommendations for use. J Ho…

  3. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. | PSNet

    psnet.ahrq.gov/issue/association-between-concurrent-use-prescription-opioids-and-benzodiazepines-and-overdose
    November 16, 2022 - Study Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. Citation Text: Sun EC, Dixit A, Humphreys K, et al. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analys…

  4. Expanded pharmacy technician roles: accepting verbal prescriptions and communicating prescription transfers. | PSNet

    psnet.ahrq.gov/issue/expanded-pharmacy-technician-roles-accepting-verbal-prescriptions-and-communicating
    October 05, 2011 - Commentary Expanded pharmacy technician roles: accepting verbal prescriptions and communicating prescription transfers. Citation Text: Frost TP, Adams AJ. Expanded pharmacy technician roles: Accepting verbal prescriptions and communicating prescription transfers. Res Social Adm Pharm. 20…

  5. Computerized physician order entry in the critical care environment: a review of current literature. | PSNet

    psnet.ahrq.gov/issue/computerized-physician-order-entry-critical-care-environment-review-current-literature
    September 19, 2012 - Review Computerized physician order entry in the critical care environment: a review of current literature. Citation Text: Maslove DM, Rizk NW, Lowe HJ. Computerized Physician Order Entry in the Critical Care Environment: A Review of Current Literature. J Intensive Care Med. 2011;26(3)…

  6. Rapid learning of adverse medical event disclosure and apology. | PSNet

    psnet.ahrq.gov/issue/rapid-learning-adverse-medical-event-disclosure-and-apology
    November 04, 2014 - Study Rapid learning of adverse medical event disclosure and apology. Citation Text: Raemer D, Locke S, Walzer TB, et al. Rapid Learning of Adverse Medical Event Disclosure and Apology. J Patient Saf. 2016;12(3):140-7. doi:10.1097/PTS.0000000000000080. Copy Citation Format: …

  7. Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards. | PSNet

    psnet.ahrq.gov/issue/track-trigger-and-teamwork-communication-deterioration-acute-medical-and-surgical-wards
    August 06, 2014 - Study Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards. Citation Text: Donohue LA, Endacott R. Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards. Intensive Crit Care Nurs. 2010;26(1):10-7. doi:…

  8. Post-event debriefings during neonatal care: why are we not doing them, and how can we start? | PSNet

    psnet.ahrq.gov/issue/post-event-debriefings-during-neonatal-care-why-are-we-not-doing-them-and-how-can-we-start
    January 15, 2014 - Commentary Post-event debriefings during neonatal care: why are we not doing them, and how can we start? Citation Text: Sawyer T, Loren D, Halamek LP. Post-event debriefings during neonatal care: why are we not doing them, and how can we start? J Perinatol. 2016;36(6):415-9. doi:10.1038/…

  9. From battles to burnout: investigating the role of interphysician conflict in physician burnout. | PSNet

    psnet.ahrq.gov/issue/battles-burnout-investigating-role-interphysician-conflict-physician-burnout
    August 23, 2023 - Study From battles to burnout: investigating the role of interphysician conflict in physician burnout. Citation Text: Amick AE, Schrepel C, Bann M, et al. From battles to burnout: investigating the role of interphysician conflict in physician burnout. Acad Med. 2023;98(9):1076-1082. doi:…

  10. Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. | PSNet

    psnet.ahrq.gov/issue/using-situ-simulation-improve-hospital-cardiopulmonary-resuscitation
    January 02, 2017 - Study Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. Citation Text: Lighthall GK, Poon T, Harrison K. Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. Jt Comm J Qual Patient Saf. 2010;36(5):209-16. Copy Citation Format: …

  11. The effect of opioid prescribing guidelines on prescriptions by emergency physicians in Ohio. | PSNet

    psnet.ahrq.gov/issue/effect-opioid-prescribing-guidelines-prescriptions-emergency-physicians-ohio
    April 24, 2018 - Study The effect of opioid prescribing guidelines on prescriptions by emergency physicians in Ohio. Citation Text: Weiner SG, Baker O, Poon SJ, et al. The Effect of Opioid Prescribing Guidelines on Prescriptions by Emergency Physicians in Ohio. Ann Emerg Med. 2017;70(6):799-808.e1. doi:1…

  12. 5-Red-Light-Green-Light (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/5-red-light-green-light.docx
    June 01, 2023 - AHRQ Safety Program for Improving Surgical Care and Recovery Red Light, Green Light: An Overview of Common Implementation Barriers and Facilitators Purpose of this tool: To help team leaders identify barriers to and facilitators of implementing Improving Surgical Care and Recovery (ISCR), an enhanced recovery program…

  13. Rapid response systems: a prospective study of response times. | PSNet

    psnet.ahrq.gov/issue/rapid-response-systems-prospective-study-response-times
    November 16, 2022 - Study Rapid response systems: a prospective study of response times. Citation Text: Adelstein B-A, Piza MA, Nayyar V, et al. Rapid response systems: a prospective study of response times. J Crit Care. 2011;26(6):635.e11-8. doi:10.1016/j.jcrc.2011.03.013. Copy Citation Format: …

  14. Assessing clinical reasoning: targeting the higher levels of the pyramid. | PSNet

    psnet.ahrq.gov/issue/assessing-clinical-reasoning-targeting-higher-levels-pyramid
    June 15, 2022 - Commentary Assessing clinical reasoning: targeting the higher levels of the pyramid. Citation Text: Thampy H, Willert E, Ramani S. Assessing Clinical Reasoning: Targeting the Higher Levels of the Pyramid. J Gen Intern Med. 2019;34(8):1631-1636. doi:10.1007/s11606-019-04953-4. Copy Cita…

  15. Opioid prescribing and potential overdose errors among children 0 to 36 months old. | PSNet

    psnet.ahrq.gov/issue/opioid-prescribing-and-potential-overdose-errors-among-children-0-36-months-old
    March 23, 2016 - Study Opioid prescribing and potential overdose errors among children 0 to 36 months old. Citation Text: Basco WT, Ebeling M, Garner SS, et al. Opioid Prescribing and Potential Overdose Errors Among Children 0 to 36 Months Old. Clin Pediatr (Phila). 2015;54(8):738-44. doi:10.1177/0009922…

  16. A preliminary taxonomy of medical errors in family practice. | PSNet

    psnet.ahrq.gov/issue/preliminary-taxonomy-medical-errors-family-practice
    April 08, 2011 - Study Classic A preliminary taxonomy of medical errors in family practice. Citation Text: Dovey S, Meyers DS, Phillips RL, et al. A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care. 2002;11(3):233-8. Copy Citation Format: …

  17. Application of a human factors classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents in hospital. | PSNet

    psnet.ahrq.gov/issue/application-human-factors-classification-framework-patient-safety-identify-precursor-and
    October 21, 2015 - Study Application of a human factors classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents in hospital. Citation Text: Mitchell RJ, Williamson A, Molesworth B. Application of a human factors classification framework for p…

  18. Patient and physician experience with interhospital transfer: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/patient-and-physician-experience-interhospital-transfer-qualitative-study
    April 12, 2023 - Study Patient and physician experience with interhospital transfer: a qualitative study. Citation Text: Mueller SK, Shannon E, Dalal A, et al. Patient and Physician Experience with Interhospital Transfer: A Qualitative Study. J Patient Saf. 2021;17(8):e752-e757. doi:10.1097/PTS.000000000…

  19. Management of arterial lines and blood sampling in intensive care: a threat to patient safety. | PSNet

    psnet.ahrq.gov/issue/management-arterial-lines-and-blood-sampling-intensive-care-threat-patient-safety
    November 12, 2014 - Study Management of arterial lines and blood sampling in intensive care: a threat to patient safety. Citation Text: Leslie RA, Gouldson S, Habib N, et al. Management of arterial lines and blood sampling in intensive care: a threat to patient safety. Anaesthesia. 2013;68(11). doi:10.1111…

  20. Impact of resident workload and handoff training on patient outcomes. | PSNet

    psnet.ahrq.gov/issue/impact-resident-workload-and-handoff-training-patient-outcomes
    April 12, 2023 - Study Impact of resident workload and handoff training on patient outcomes. Citation Text: Mueller SK, Call S, McDonald FS, et al. Impact of resident workload and handoff training on patient outcomes. Am J Med. 2012;125(1):104-10. doi:10.1016/j.amjmed.2011.09.005. Copy Citation F…
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