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psnet.ahrq.gov/issue/towards-model-surgeons-leadership-operating-room
July 01, 2020 - Review
Towards a model of surgeons' leadership in the operating room.
Citation Text:
Parker SH, Yule S, Flin R, et al. Towards a model of surgeons' leadership in the operating room. BMJ Qual Saf. 2011;20(7):570-9. doi:10.1136/bmjqs.2010.040295.
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psnet.ahrq.gov/issue/role-apology-laws-medical-malpractice
July 29, 2020 - Commentary
The role of apology laws in medical malpractice.
Citation Text:
The role of apology laws in medical malpractice. Ross NE, Newman WJ. J Am Acad Psychiatry Law. 2021;49(3):406-414.
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psnet.ahrq.gov/issue/why-patient-safety-such-tough-nut-crack
May 03, 2023 - Commentary
Why patient safety is such a tough nut to crack.
Citation Text:
Leistikow IP, Kalkman CJ, de Bruijn H. Why patient safety is such a tough nut to crack. BMJ. 2011;342:d3447. doi:10.1136/bmj.d3447.
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psnet.ahrq.gov/issue/keeping-nursing-home-residents-and-staff-safe-era-covid-19
November 11, 2020 - Meeting/Conference Proceedings
Keeping Nursing Home Residents and Staff Safe in the Era of COVID-19.
Citation Text:
Keeping Nursing Home Residents and Staff Safe in the Era of COVID-19. National Academy of Medicine. April-June 2020.
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psnet.ahrq.gov/issue/us-nursing-homes-where-covid-19-killed-scores-even-reports-maggots-and-rape-dont-dock-five
December 22, 2021 - Newspaper/Magazine Article
In U.S. nursing homes, where Covid-19 killed scores, even reports of maggots and rape don’t dock five-star ratings.
Citation Text:
In U.S. nursing homes, where Covid-19 killed scores, even reports of maggots and rape don’t dock five-star ratings. Silver-Greenbe…
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psnet.ahrq.gov/issue/lost-sponge-patient-safety-operating-room
January 26, 2022 - Commentary
The lost sponge: patient safety in the operating room.
Citation Text:
Grant-Orser A, Davies P, Singh SS. The lost sponge: patient safety in the operating room. CMAJ . 2012;184(11):1275-1278. doi:10.1503/cmaj.110900.
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psnet.ahrq.gov/issue/high-reliability-truly-achieving-healthcare-quality-and-safety
March 18, 2019 - Commentary
High reliability: truly achieving healthcare quality and safety.
Citation Text:
Kaplan GS. Pursuing the perfect patient experience. Front Health Serv Manage. 2013;29(3):16-27.
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psnet.ahrq.gov/issue/quantifying-distraction-and-interruption-urological-surgery
March 11, 2009 - Study
Quantifying distraction and interruption in urological surgery.
Citation Text:
Healey A, Primus CP, Koutantji M. Quantifying distraction and interruption in urological surgery. Qual Saf Health Care. 2007;16(2):135-9.
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psnet.ahrq.gov/issue/medication-reconciliation-only-good-it-allows
July 10, 2024 - Newspaper/Magazine Article
Medication reconciliation only as good as the IT allows.
Citation Text:
Page D. Medication reconciliation only as good as the IT allows. Hospitals & health networks. 2011;85(3):48, 50.
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psnet.ahrq.gov/issue/prevent-medication-errors-new-years-resolution-teaching-patients-about-their-medications
January 18, 2011 - Commentary
Prevent medication errors: a New Year's resolution: teaching patients about their medications.
Citation Text:
Polzien G. Prevent medication errors: A New Year's resolution: teaching patients about their medications. Home Healthc Nurse. 2007;25(1):59-62.
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psnet.ahrq.gov/issue/high-costs-unnecessary-care
June 28, 2023 - Commentary
The high costs of unnecessary care.
Citation Text:
Carroll AE. The High Costs of Unnecessary Care. JAMA. 2017;318(18):1748-1749. doi:10.1001/jama.2017.16193.
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psnet.ahrq.gov/issue/human-factors-subsystems-approach-trauma-care
October 08, 2013 - Study
A human factors subsystems approach to trauma care.
Citation Text:
Catchpole K, Ley EJ, Wiegmann D, et al. A human factors subsystems approach to trauma care. JAMA Surg. 2014;149(9):962-8.
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psnet.ahrq.gov/issue/taking-aim-infusion-confusion
June 06, 2018 - Commentary
Taking aim at infusion confusion.
Citation Text:
Burdeu G, Crawford R, Van de Vreede M, et al. Taking aim at infusion confusion. J Nurs Care Qual. 2006;21(2):151-159.
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psnet.ahrq.gov/issue/quality-and-safety-pediatric-hematologyoncology
May 03, 2017 - Review
Quality and safety in pediatric hematology/oncology.
Citation Text:
Mueller BU. Quality and safety in pediatric hematology/oncology. Pediatr Blood Cancer. 2014;61(6):966-9. doi:10.1002/pbc.24946.
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psnet.ahrq.gov/issue/medication-therapy-management-programs-forming-new-cornerstone-quality-and-safety-medicare
January 06, 2017 - Commentary
Medication therapy management programs: forming a new cornerstone for quality and safety in Medicare.
Citation Text:
Smith SR, Clancy CM. Medication therapy management programs: forming a new cornerstone for quality and safety in medicare. Am J Med Qual. 2006;21(4):276-9.
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psnet.ahrq.gov/issue/call-excellence
May 20, 2009 - Commentary
A call to excellence.
Citation Text:
Clancy CM, Scully T. A call to excellence. Health Aff (Millwood). 2003;22(2):113-5.
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psnet.ahrq.gov/issue/path-safety-benefits-2005-patient-safety-and-quality-improvement-act
June 03, 2015 - Commentary
Path to safety: benefits of the 2005 Patient Safety and Quality Improvement Act.
Citation Text:
McBride D, Greening A, Redmond D. Path to safety: benefits of the 2005 Patient Safety and Quality Improvement Act. Healthc Financ Manage. 2006;60(6):84-8.
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psnet.ahrq.gov/issue/morphine-overdose-error-propagation-acute-pain-service-une-surdose-de-morphine-resultant-de
January 13, 2016 - Commentary
Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue].
Citation Text:
Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant …
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www.ahrq.gov/sites/default/files/2025-03/smith-werner-carayon-report.pdf
January 01, 2025 - Study design
We conducted a participatory design approach to integrate the needs of multiple stakeholders
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/157-what-are-4-es.docx
October 01, 2024 - Additionally, the team intends to integrate MRSA training into the annual recertification process, including