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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - Integrating handoff evaluation with supervision of trainees.
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psnet.ahrq.gov/issue/patient-safety-marginalised-groups-narrative-scoping-review
August 26, 2015 - Review
Patient safety in marginalised groups: a narrative scoping review
Citation Text:
Cheraghi-Sohi S, Panagioti M, Daker-White G, et al. Patient safety in marginalised groups: a narrative scoping review. Int J Equity Health. 2020;19(1):26. doi:10.1186/s12939-019-1103-2.
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psnet.ahrq.gov/issue/quasi-experimental-evaluation-effectiveness-large-scale-readmission-reduction-program
January 07, 2015 - Study
Quasi-experimental evaluation of the effectiveness of a large-scale readmission reduction program.
Citation Text:
Jenq GY, Doyle MM, Belton BM, et al. Quasi-Experimental Evaluation of the Effectiveness of a Large-Scale Readmission Reduction Program. JAMA Intern Med. 2016;176(5):681…
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psnet.ahrq.gov/issue/effect-transformation-veterans-affairs-health-care-system-quality-care
July 28, 2014 - Study
Classic
Effect of the transformation of the Veterans Affairs Health Care System on the quality of care.
Citation Text:
Jha AK, Perlin JB, Kizer KW, et al. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N E…
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psnet.ahrq.gov/issue/workarounds-barcode-medication-administration-systems-their-occurrences-causes-and-threats
November 30, 2011 - Study
Classic
Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety.
Citation Text:
Koppel R, Wetterneck TB, Telles JL, et al. Workarounds to barcode medication administration systems: their occurren…
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psnet.ahrq.gov/issue/board-bedside-how-application-financial-structures-safety-and-quality-can-drive
January 29, 2015 - Study
From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system.
Citation Text:
Austin M, Demski R, Callender T, et al. From Board to Bedside: How the Application of Financial Structures to Safety and Q…
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psnet.ahrq.gov/issue/diagnostic-accuracy-gps-when-using-early-intervention-decision-support-system-high-fidelity
April 03, 2018 - Study
Diagnostic accuracy of GPs when using an early-intervention decision support system: a high-fidelity simulation.
Citation Text:
Kostopoulou O, Porat T, Corrigan D, et al. Diagnostic accuracy of GPs when using an early-intervention decision support system: a high-fidelity simulation…
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psnet.ahrq.gov/issue/estimating-economic-cost-nurse-sensitive-adverse-events-amongst-patients-medical-and-surgical
July 11, 2018 - Study
Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings.
Citation Text:
Murphy A, Griffiths P, Duffield C, et al. Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical setting…
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psnet.ahrq.gov/issue/association-between-mobile-telephone-interruptions-and-medication-administration-errors
June 29, 2009 - Study
Association between mobile telephone interruptions and medication administration errors in a pediatric intensive care unit.
Citation Text:
Bonafide CP, Miller JM, Localio AR, et al. Association between mobile telephone interruptions and medication administration errors in a pediatr…
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psnet.ahrq.gov/issue/impact-comprehensive-unit-based-safety-program-cusp-safety-culture-surgical-inpatient-unit
January 03, 2017 - Study
Impact of the Comprehensive Unit-Based Safety Program (CUSP) on safety culture in a surgical inpatient unit.
Citation Text:
Timmel J, Kent P, Holzmueller CG, et al. Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm …
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psnet.ahrq.gov/issue/inadequate-hand-communication
April 02, 2015 - Sentinel Event Alerts
Inadequate hand-off communication.
Citation Text:
Inadequate hand-off communication. Sentinel event alert. 2017;58(58):1-6.
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psnet.ahrq.gov/issue/large-scale-observational-study-ai-based-patient-and-surgical-material-verification-system
August 27, 2012 - Study
Large-scale observational study of AI-based patient and surgical material verification system in ophthalmology: real-world evaluation in 37 529 cases.
Citation Text:
Tabuchi H, Ishitobi N, Deguchi H, et al. Large-scale observational study of AI-based patient and surgical material v…
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psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
September 01, 2012 - Preparing for Health Reform: The Federal Government and the Nursing Workforce
Peter I. Buerhaus, PhD, RN | September 1, 2012
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View more articles from the same authors.
Citation Text:
Buerhaus P. Preparing for Health Reform: The Federal G…
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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - Errors and Near Misses: What Health Care Could Learn From Aviation
Carl Macrae, PhD | December 1, 2016
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation…
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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psnet.ahrq.gov/node/867753/psn-pdf
March 12, 2025 - Enhancing patient safety and risk management through
clinical pathways in oncology.
March 12, 2025
Milanesi M, Fiorito R, Caloccia L, et al. Enhancing patient safety and risk management through clinical
pathways in oncology. BMJ Open Qual. 2025;14(1):e003012. doi:10.1136/bmjoq-2024-003012.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/web-mm/polypharmacy
March 01, 2007 - Polypharmacy
Citation Text:
Guglielmo JB. Polypharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - Nursing and Patient Safety
Citation Text:
Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/issue/patient-specific-electronic-decision-support-reduces-prescription-excessive-doses
November 02, 2010 - Study
Patient-specific electronic decision support reduces prescription of excessive doses.
Citation Text:
Seidling HM, Schmitt SPW, Bruckner T, et al. Patient-specific electronic decision support reduces prescription of excessive doses. Qual Saf Health Care. 2010;19(5):e15. doi:10.113…
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psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
August 01, 2009 - Journal Article
Study
Catching those who fall through the cracks: integrating