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psnet.ahrq.gov/issue/learning-near-misses-quick-fixes-closing-swiss-cheese-holes
April 11, 2012 - Study
Learning from near misses: from quick fixes to closing off the Swiss-cheese holes.
Citation Text:
Jeffs L, Berta W, Lingard LA, et al. Learning from near misses: from quick fixes to closing off the Swiss-cheese holes. BMJ Qual Saf. 2012;21(4):287-94. doi:10.1136/bmjqs-2011-000256…
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psnet.ahrq.gov/issue/comparing-errors-ed-computer-assisted-vs-conventional-pediatric-drug-dosing-and
November 22, 2017 - Study
Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration.
Citation Text:
Yamamoto LG, Kanemori J. Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration. Am J Emerg Med. 2010;28(5):588-92. doi:10.…
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psnet.ahrq.gov/issue/tension-between-needing-improve-care-and-knowing-how-do-it
June 03, 2010 - Commentary
Classic
The tension between needing to improve care and knowing how to do it.
Citation Text:
Auerbach AD, Landefeld S, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med. 2007;357(6):608-13.
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psnet.ahrq.gov/issue/educating-medical-trainees-medication-reconciliation-systematic-review
October 16, 2019 - Review
Educating medical trainees on medication reconciliation: a systematic review.
Citation Text:
Ramjaun A, Sudarshan M, Patakfalvi L, et al. Educating medical trainees on medication reconciliation: a systematic review. BMC Med Educ. 2015;15:33. doi:10.1186/s12909-015-0306-5.
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psnet.ahrq.gov/issue/when-covid-19-hit-many-elderly-were-left-die
June 24, 2020 - Newspaper/Magazine Article
When COVID-19 hit, many elderly were left to die.
Citation Text:
Stevis-Gridneff M, Apuzzo M, Pronczuk M. When COVID-19 hit, many elderly were left to die. New York Times. 2020;August 8.
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psnet.ahrq.gov/issue/how-safety-climate-measured-review-and-evaluation
January 26, 2022 - Review
How is safety climate measured? A review and evaluation.
Citation Text:
Shea T, De Cieri H, Vu T, et al. How is safety climate measured? A review and evaluation. Safety Sci. 2021;143:105413. doi:10.1016/j.ssci.2021.105413.
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psnet.ahrq.gov/issue/perspective-culture-respect-part-1-and-part-2
October 04, 2006 - Commentary
Perspective: a culture of respect—part 1 and part 2.
Citation Text:
Perspective: a culture of respect—part 1 and part 2. Leape LL, Shore MF, Dienstag JL, et al. Acad Med. 2012;87(7):845-858.
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psnet.ahrq.gov/issue/attitudes-nursing-students-and-clinical-instructors-towards-reporting-irregular-incidents
June 01, 2019 - Study
The attitudes of nursing students and clinical instructors towards reporting irregular incidents in the medical clinic.
Citation Text:
Halperin O, Bronshtein O. The attitudes of nursing students and clinical instructors towards reporting irregular incidents in the medical clinic. N…
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psnet.ahrq.gov/issue/trends-and-patterns-reporting-patient-safety-situations-transplantation
October 19, 2022 - Study
Trends and patterns in reporting of patient safety situations in transplantation.
Citation Text:
Stewart DE, Tlusty SM, Taylor KH, et al. Trends and Patterns in Reporting of Patient Safety Situations in Transplantation. Am J Transplant. 2015;15(12):3123-33. doi:10.1111/ajt.13528.
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psnet.ahrq.gov/issue/predictors-healthcare-professionals-attitudes-towards-family-involvement-safety-relevant
November 05, 2013 - Study
Predictors of healthcare professionals' attitudes towards family involvement in safety-relevant behaviours: a cross-sectional factorial survey study.
Citation Text:
Davis R, Savvopoulou M, Shergill R, et al. Predictors of healthcare professionals' attitudes towards family involveme…
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psnet.ahrq.gov/issue/patient-safety-and-staff-competence-managing-challenging-behavior-based-feedback-former
October 15, 2016 - Study
Patient safety and staff competence in managing challenging behavior based on feedback from former psychiatric patients.
Citation Text:
Tölli S, Kontio R, Partanen P, et al. Patient safety and staff competence in managing challenging behavior based on feedback from former psychiatr…
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psnet.ahrq.gov/issue/impact-implementation-family-initiated-escalation-care-deteriorating-patient-hospital
December 21, 2018 - Review
The impact of implementation of family-initiated escalation of care for the deteriorating patient in hospital: a systematic review.
Citation Text:
Gill FJ, Leslie GD, Marshall AP. The Impact of Implementation of Family-Initiated Escalation of Care for the Deteriorating Patient in …
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psnet.ahrq.gov/issue/influence-organizational-context-quality-improvement-and-patient-safety-efforts-infection
May 08, 2017 - Study
The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study.
Citation Text:
Krein SL, Damschroder LJ, Kowalski CP, et al. The influence of organizational context on quality improvement and pat…
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psnet.ahrq.gov/issue/ladder-based-safety-culture-assessments-inversely-predict-safety-outcomes
January 22, 2025 - Commentary
‘Ladder’-based safety culture assessments inversely predict safety outcomes.
Citation Text:
Boskeljon‐Horst L, Sillem S, Dekker SWA. ‘Ladder’‐based safety culture assessments inversely predict safety outcomes. J Contingencies Crisis Manag. 2022;31(3):372-391. doi:10.1111/1468-…
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psnet.ahrq.gov/issue/electronic-test-result-communication-era-21st-century-cures-act
May 25, 2022 - Book/Report
Electronic Test Result Communication in the Era of the 21st Century Cures Act
Citation Text:
Bradford A, Ehsan S, Shahid U, et al. Electronic Test Result Communication In The Era Of The 21St Century Cures Act. Rockville, MD: Agency for Healthcare Research and Quality; July 20…
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psnet.ahrq.gov/issue/intraoperative-code-blue-improving-teamwork-and-code-response-through-interprofessional-situ
April 28, 2021 - Study
Intraoperative code blue: improving teamwork and code response through interprofessional, in situ simulation.
Citation Text:
Wu G, Podlinski L, Wang C, et al. Intraoperative code blue: improving teamwork and code response through interprofessional, in situ simulation. Jt Comm J Qua…
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psnet.ahrq.gov/issue/measurement-performance-driver-case-national-measurement-system-improve-patient-safety
September 01, 2018 - Review
Measurement as a performance driver: the case for a national measurement system to improve patient safety.
Citation Text:
Krause TR, Bell KJ, Pronovost P, et al. Measurement as a Performance Driver: The Case for a National Measurement System to Improve Patient Safety. J Patient Sa…
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psnet.ahrq.gov/issue/operating-room-organization-and-surgical-performance-systematic-review
March 05, 2025 - Review
Operating room organization and surgical performance: a systematic review.
Citation Text:
Pasquer A, Ducarroz S, Lifante JC, et al. Operating room organization and surgical performance: a systematic review. Patient Saf Surg. 2024;18(1):5. doi:10.1186/s13037-023-00388-3.
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psnet.ahrq.gov/issue/effect-clinician-feedback-interventions-opioid-prescribing
November 17, 2021 - Study
The effect of clinician feedback interventions on opioid prescribing.
Citation Text:
Navathe AS, Liao JM, Yan XS, et al. The effect of clinician feedback interventions on opioid prescribing. Health Aff (Millwood). 2022;41(3):424-433. doi:10.1377/hlthaff.2021.01407.
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psnet.ahrq.gov/issue/closing-gap-and-raising-bar-assessing-board-competency-quality-and-safety
July 20, 2022 - Study
Closing the gap and raising the bar: assessing board competency in quality and safety.
Citation Text:
McGaffigan PA, Ullem BD, Gandhi TK. Closing the Gap and Raising the Bar: Assessing Board Competency in Quality and Safety. Jt Comm J Qual Patient Saf. 2017;43(6):267-274. doi:10.10…