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  1. Implementation of a standardized tool for root cause analysis selection. | PSNet

    psnet.ahrq.gov/issue/implementation-standardized-tool-root-cause-analysis-selection
    November 06, 2024 - Study Implementation of a standardized tool for root cause analysis selection. Citation Text: Wahlstedt E, Levy BE, Scott E, et al. Implementation of a standardized tool for root cause analysis selection. J Patient Saf. 2025;21(2):101-105. doi:10.1097/pts.0000000000001291. Copy Citatio…

  2. Digital maturity as a predictor of quality and safety outcomes in US hospitals: cross-sectional observational study. | PSNet

    psnet.ahrq.gov/issue/digital-maturity-predictor-quality-and-safety-outcomes-us-hospitals-cross-sectional
    September 04, 2024 - Study Digital maturity as a predictor of quality and safety outcomes in US hospitals: cross-sectional observational study. Citation Text: Snowdon A, Hussein A, Danforth M, et al. Digital maturity as a predictor of quality and safety outcomes in US hospitals: cross-sectional observational…

  3. A human right-based approach to dealing with adverse events in residential care facilities. | PSNet

    psnet.ahrq.gov/issue/human-right-based-approach-dealing-adverse-events-residential-care-facilities
    May 27, 2011 - Study A human right-based approach to dealing with adverse events in residential care facilities. Citation Text: McGrane N, Behan L, Keyes LM. A human right-based approach to dealing with adverse events in residential care facilities. Health Hum Rights. 2024;26(1):115-128. Copy Citatio…

  4. Effects of racial bias in pulse oximetry on children and how to address algorithmic bias in clinical medicine. | PSNet

    psnet.ahrq.gov/issue/effects-racial-bias-pulse-oximetry-children-and-how-address-algorithmic-bias-clinical
    May 08, 2017 - Commentary Effects of racial bias in pulse oximetry on children and how to address algorithmic bias in clinical medicine. Citation Text: Gray KD, Subramaniam HL, Huang ES. Effects of racial bias in pulse oximetry on children and how to address algorithmic bias in clinical medicine. JAMA …

  5. Accidental deaths, saved lives, and improved quality. | PSNet

    psnet.ahrq.gov/issue/accidental-deaths-saved-lives-and-improved-quality
    February 04, 2015 - Commentary Classic Accidental deaths, saved lives, and improved quality. Citation Text: Brennan TA, Gawande AA, Thomas EJ, et al. Accidental Deaths, Saved Lives, and Improved Quality. New England Journal of Medicine. 2005;353(13). doi:10.1056/nejmsb051157. C…

  6. Design of an evidence-based "second victim" curriculum for nurse anesthetists. | PSNet

    psnet.ahrq.gov/issue/design-evidence-based-second-victim-curriculum-nurse-anesthetists
    February 15, 2023 - Commentary Design of an evidence-based "second victim" curriculum for nurse anesthetists. Citation Text: Daniels RG, McCorkle R. Design of an Evidence-Based "Second Victim" Curriculum for Nurse Anesthetists. AANA J. 2016;84(2):107-113. Copy Citation Format: Google Scholar P…

  7. Client, caregiver, and provider perspectives of safety in palliative home care: a mixed method design. | PSNet

    psnet.ahrq.gov/issue/client-caregiver-and-provider-perspectives-safety-palliative-home-care-mixed-method-design
    March 02, 2016 - Study Client, caregiver, and provider perspectives of safety in palliative home care: a mixed method design. Citation Text: Lang A, Toon L, Cohen SR, et al. Client, caregiver, and provider perspectives of safety in palliative home care: a mixed method design. Safety Health. 2015;1(1):3. …

  8. Important factors for effective patient safety governance auditing: a questionnaire survey. | PSNet

    psnet.ahrq.gov/issue/important-factors-effective-patient-safety-governance-auditing-questionnaire-survey
    December 04, 2015 - Study Important factors for effective patient safety governance auditing: a questionnaire survey. Citation Text: van Gelderen SC, Zegers M, Robben PB, et al. Important factors for effective patient safety governance auditing: a questionnaire survey. BMC Health Serv Res. 2018;18(1):798. d…

  9. The Swiss Cheese Conference: integrating and aligning quality improvement education with hospital patient safety initiatives. | PSNet

    psnet.ahrq.gov/issue/swiss-cheese-conference-integrating-and-aligning-quality-improvement-education-hospital
    March 14, 2016 - Commentary The Swiss Cheese Conference: integrating and aligning quality improvement education with hospital patient safety initiatives. Citation Text: Durstenfeld MS, Statman S, Dikman A, et al. The Swiss Cheese Conference: integrating and aligning quality improvement education with hos…

  10. Lack of association between intraoperative handoff of care and postoperative complications: a retrospective observational study. | PSNet

    psnet.ahrq.gov/issue/lack-association-between-intraoperative-handoff-care-and-postoperative-complications
    March 14, 2022 - Study Lack of association between intraoperative handoff of care and postoperative complications: a retrospective observational study. Citation Text: O'Reilly-Shah VN, Melanson VG, Sullivan CL, et al. Lack of association between intraoperative handoff of care and postoperative complicat…

  11. Strategies that facilitate the delivery of exceptionally good patient care in general practice: a qualitative study with patients and primary care professionals. | PSNet

    psnet.ahrq.gov/issue/strategies-facilitate-delivery-exceptionally-good-patient-care-general-practice-qualitative
    February 24, 2021 - Study Strategies that facilitate the delivery of exceptionally good patient care in general practice: a qualitative study with patients and primary care professionals. Citation Text: O’Malley R, O’Connor P, Lydon S. Strategies that facilitate the delivery of exceptionally good patient ca…

  12. Perceptions of hospital safety climate and incidence of readmission. | PSNet

    psnet.ahrq.gov/issue/perceptions-hospital-safety-climate-and-incidence-readmission
    March 25, 2015 - Study Perceptions of hospital safety climate and incidence of readmission. Citation Text: Hansen LO, Williams M, Singer SJ. Perceptions of hospital safety climate and incidence of readmission. Health Serv Res. 2011;46(2):596-616. doi:10.1111/j.1475-6773.2010.01204.x. Copy Citation …

  13. Nursing turbulence in critical care: relationships with nursing workload and patient safety. | PSNet

    psnet.ahrq.gov/issue/nursing-turbulence-critical-care-relationships-nursing-workload-and-patient-safety
    October 19, 2022 - Study Nursing turbulence in critical care: relationships with nursing workload and patient safety. Citation Text: Browne J, Braden CJ. Nursing turbulence in critical care: relationships with nursing workload and patient safety. Am J Crit Care. 2020;29(3):182-191. doi:10.4037/ajcc2020180.…

  14. Morbidity and mortality conferences: a narrative review of strategies to prioritize quality improvement. | PSNet

    psnet.ahrq.gov/issue/morbidity-and-mortality-conferences-narrative-review-strategies-prioritize-quality
    January 11, 2023 - Review Morbidity and mortality conferences: a narrative review of strategies to prioritize quality improvement. Citation Text: Giesbrecht V, Au S. Morbidity and Mortality Conferences: A Narrative Review of Strategies to Prioritize Quality Improvement. Jt Comm J Qual Patient Saf. 2016;42(…

  15. The impact of burnout on paediatric nurses' attitudes about patient safety in the acute hospital setting: a systematic review. | PSNet

    psnet.ahrq.gov/issue/impact-burnout-paediatric-nurses-attitudes-about-patient-safety-acute-hospital-setting
    June 05, 2019 - Review The impact of burnout on paediatric nurses' attitudes about patient safety in the acute hospital setting: a systematic review. Citation Text: Flynn C, Watson C, Patton D, et al. The impact of burnout on paediatric nurses' attitudes about patient safety in the acute hospital setti…

  16. Reasons for repeat rapid response team calls, and associations with in-hospital mortality. | PSNet

    psnet.ahrq.gov/issue/reasons-repeat-rapid-response-team-calls-and-associations-hospital-mortality
    March 03, 2020 - Study Reasons for repeat rapid response team calls, and associations with in-hospital mortality. Citation Text: Chalwin R, Giles L, Salter A, et al. Reasons for Repeat Rapid Response Team Calls, and Associations with In-Hospital Mortality. Jt Comm J Qual Patient Saf. 2019;45(4):268-275. …

  17. Patient engagement with surgical site infection prevention: an expert panel perspective. | PSNet

    psnet.ahrq.gov/issue/patient-engagement-surgical-site-infection-prevention-expert-panel-perspective
    June 03, 2020 - Review Patient engagement with surgical site infection prevention: an expert panel perspective. Citation Text: Tartari E, Weterings V, Gastmeier P, et al. Patient engagement with surgical site infection prevention: an expert panel perspective. Antimicrob Resist Infect Control. 2017;6:45.…

  18. Pathology trainees rarely report safety incidents: a review of 13,722 safety reports and a call to action. | PSNet

    psnet.ahrq.gov/issue/pathology-trainees-rarely-report-safety-incidents-review-13722-safety-reports-and-call-action
    September 15, 2021 - Study Pathology trainees rarely report safety incidents: a review of 13,722 safety reports and a call to action. Citation Text: Harris CK, Chen Y, Yarsky B, et al. Pathology trainees rarely report safety incidents: a review of 13,722 safety reports and a call to action. Acad Pathol. 2022…

  19. Educational targets to reduce medication errors by general surgery residents. | PSNet

    psnet.ahrq.gov/issue/educational-targets-reduce-medication-errors-general-surgery-residents
    October 19, 2022 - Study Educational targets to reduce medication errors by general surgery residents. Citation Text: Chaitoff A, Strong AT, Bauer SR, et al. Educational Targets to Reduce Medication Errors by General Surgery Residents. J Surg Educ. 2019;76(6):1612-1621. doi:10.1016/j.jsurg.2019.04.009. C…

  20. Improving safety in the operating room: medication icon labels increase visibility and discrimination. | PSNet

    psnet.ahrq.gov/issue/improving-safety-operating-room-medication-icon-labels-increase-visibility-and-discrimination
    April 03, 2019 - Study Improving safety in the operating room: medication icon labels increase visibility and discrimination. Citation Text: Lusk C, Catchpole K, Neyens DM, et al. Improving safety in the operating room: medication icon labels increase visibility and discrimination. Appl Ergon. 2022;104:1…
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