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  1. Surgical team training: promoting high reliability with nontechnical skills. | PSNet

    psnet.ahrq.gov/issue/surgical-team-training-promoting-high-reliability-nontechnical-skills
    May 01, 2019 - Commentary Surgical team training: promoting high reliability with nontechnical skills. Citation Text: Paige JT. Surgical team training: promoting high reliability with nontechnical skills. Surg Clin North Am. 2010;90(3):569-81. doi:10.1016/j.suc.2010.02.007. Copy Citation Format…

  2. Older veterans and emergency department discharge information. | PSNet

    psnet.ahrq.gov/issue/older-veterans-and-emergency-department-discharge-information
    March 02, 2011 - Study Older veterans and emergency department discharge information. Citation Text: Hastings S, Stechuchak K, Oddone E, et al. Older veterans and emergency department discharge information. BMJ Qual Saf. 2012;21(10):835-42. Copy Citation Format: Google Scholar PubMed BibT…

  3. Increasing the use of 'smart' pump drug libraries by nurses: a continuous quality improvement project. | PSNet

    psnet.ahrq.gov/issue/increasing-use-smart-pump-drug-libraries-nurses-continuous-quality-improvement-project
    September 09, 2020 - Commentary Increasing the use of 'smart' pump drug libraries by nurses: a continuous quality improvement project. Citation Text: Harding AD. Increasing the use of 'smart' pump drug libraries by nurses: a continuous quality improvement project. Am J Nurs. 2012;112(1):26-37. doi:10.1097/…

  4. Safety in office-based anesthesia: an updated review of the literature from 2016 to 2019 | PSNet

    psnet.ahrq.gov/issue/safety-office-based-anesthesia-updated-review-literature-2016-2019
    February 10, 2021 - Review Safety in office-based anesthesia: an updated review of the literature from 2016 to 2019 Citation Text: de Lima A, Osman BM, Shapiro FE. Safety in office-based anesthesia. Curr Opin Anaesthesiol. 2019;32(6):749-755. doi:10.1097/aco.0000000000000794. Copy Citation Format: …

  5. Disseminating innovations in health care. | PSNet

    psnet.ahrq.gov/issue/disseminating-innovations-health-care
    August 04, 2021 - Commentary Classic Disseminating innovations in health care. Citation Text: Berwick DM. Disseminating Innovations in Health Care. JAMA. 2003;289(15):1969-1975. doi:10.1001/jama.289.15.1969. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3…

  6. Prevention of intravenous drug incompatibilities in an intensive care unit. | PSNet

    psnet.ahrq.gov/issue/prevention-intravenous-drug-incompatibilities-intensive-care-unit
    February 28, 2009 - Study Prevention of intravenous drug incompatibilities in an intensive care unit. Citation Text: Bertsche T, Mayer Y, Stahl R, et al. Prevention of intravenous drug incompatibilities in an intensive care unit. Am J Health Syst Pharm. 2008;65(19):1834-40. doi:10.2146/ajhp070633. Copy …

  7. Deaths following prehospital safety incidents: an analysis of a national database. | PSNet

    psnet.ahrq.gov/issue/deaths-following-prehospital-safety-incidents-analysis-national-database
    October 03, 2018 - Study Deaths following prehospital safety incidents: an analysis of a national database. Citation Text: Yardley I, Donaldson LJ. Deaths following prehospital safety incidents: an analysis of a national database. Emerg Med J. 2016;33(10):716-721. doi:10.1136/emermed-2015-204724. Copy Ci…

  8. Designing highly reliable adverse-event detection systems to predict subsequent claims. | PSNet

    psnet.ahrq.gov/issue/designing-highly-reliable-adverse-event-detection-systems-predict-subsequent-claims
    September 01, 2018 - Study Designing highly reliable adverse-event detection systems to predict subsequent claims. Citation Text: Helmchen LA, Burke ME, Wojtusiak J. Designing highly reliable adverse-event detection systems to predict subsequent claims. J Healthc Risk Manag. 2015;34(4):7-17. doi:10.1002/jhrm…

  9. Morphine sulfate oral solution 100 mg per 5 mL (20 mg/mL): medication use error—reports of accidental overdose. | PSNet

    psnet.ahrq.gov/issue/morphine-sulfate-oral-solution-100-mg-5-ml-20-mgml-medication-use-error-reports-accidental
    June 22, 2011 - Press Release/Announcement Morphine sulfate oral solution 100 mg per 5 mL (20 mg/mL): medication use error—reports of accidental overdose. Citation Text: Morphine sulfate oral solution 100 mg per 5 mL (20 mg/mL): medication use error—reports of accidental overdose. MedWatch Safety Al…

  10. Work hours regulations for house staff in psychiatry: bad or good for residency training? | PSNet

    psnet.ahrq.gov/issue/work-hours-regulations-house-staff-psychiatry-bad-or-good-residency-training
    August 04, 2021 - Review Work hours regulations for house staff in psychiatry: bad or good for residency training? Citation Text: Rasminsky S, Lomonaco A, Auchincloss E. Work Hours Regulations for House Staff in Psychiatry: Bad or Good for Residency Training? Academic Psychiatry. 2008;32(1). doi:10.1176/a…

  11. Reducing delay in diagnosis: multistage recommendation tracking. | PSNet

    psnet.ahrq.gov/issue/reducing-delay-diagnosis-multistage-recommendation-tracking
    June 19, 2012 - Study Reducing delay in diagnosis: multistage recommendation tracking. Citation Text: Wandtke B, Gallagher S. Reducing Delay in Diagnosis: Multistage Recommendation Tracking. AJR Am J Roentgenol. 2017;209(5):970-975. doi:10.2214/AJR.17.18332. Copy Citation Format: DOI Googl…

  12. Association of patient photographs and reduced retract-and-reorder events. | PSNet

    psnet.ahrq.gov/issue/association-patient-photographs-and-reduced-retract-and-reorder-events
    February 24, 2021 - Study Association of patient photographs and reduced retract-and-reorder events. Citation Text: Rzewnicki D, Kanvinde A, Gillespie S, et al. Association of patient photographs and reduced retract-and-reorder events. JAMIA Open. 2024;7(3):ooae042. doi:10.1093/jamiaopen/ooae042. Copy Cit…

  13. Improving patient safety: avoiding unread imaging exams in the National VA enterprise electronic health record. | PSNet

    psnet.ahrq.gov/issue/improving-patient-safety-avoiding-unread-imaging-exams-national-va-enterprise-electronic
    March 12, 2025 - Study Improving patient safety: avoiding unread imaging exams in the National VA enterprise electronic health record. Citation Text: Bastawrous S, Carney B. Improving Patient Safety: Avoiding Unread Imaging Exams in the National VA Enterprise Electronic Health Record. J Digit Imaging. 20…

  14. Twitter as a tool to enhance student engagement during an interprofessional patient safety course. | PSNet

    psnet.ahrq.gov/issue/twitter-tool-enhance-student-engagement-during-interprofessional-patient-safety-course
    July 08, 2020 - Study Twitter as a tool to enhance student engagement during an interprofessional patient safety course. Citation Text: Mckay M, Sanko JS, Shekhter I, et al. Twitter as a tool to enhance student engagement during an interprofessional patient safety course. J Interprof Care. 2014;28(6):56…

  15. Relating faults in diagnostic reasoning with diagnostic errors and patient harm. | PSNet

    psnet.ahrq.gov/issue/relating-faults-diagnostic-reasoning-diagnostic-errors-and-patient-harm
    April 30, 2014 - Study Relating faults in diagnostic reasoning with diagnostic errors and patient harm. Citation Text: Zwaan L, Thijs A, Wagner C, et al. Relating faults in diagnostic reasoning with diagnostic errors and patient harm. Acad Med. 2012;87(2):149-156. doi:10.1097/ACM.0b013e31823f71e6. Copy…

  16. Changes in prognosis after the first postoperative complication. | PSNet

    psnet.ahrq.gov/issue/changes-prognosis-after-first-postoperative-complication
    June 29, 2022 - Study Changes in prognosis after the first postoperative complication. Citation Text: Silber JH, Rosenbaum PR, Trudeau ME, et al. Changes in prognosis after the first postoperative complication. Med Care. 2005;43(2):122-31. Copy Citation Format: Google Scholar PubMed BibT…

  17. Diagnostic error in pediatric cancer. | PSNet

    psnet.ahrq.gov/issue/diagnostic-error-pediatric-cancer
    November 16, 2022 - Study Diagnostic error in pediatric cancer. Citation Text: Carberry AR, Hanson K, Flannery A, et al. Diagnostic Error in Pediatric Cancer. Clin Pediatr (Phila). 2017;57*1((1):11-18. doi:10.1177/0009922816687325. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML…

  18. Patient safety for people experiencing advanced dementia in hospital: a video reflexive ethnography. | PSNet

    psnet.ahrq.gov/issue/patient-safety-people-experiencing-advanced-dementia-hospital-video-reflexive-ethnography
    November 16, 2022 - Study Patient safety for people experiencing advanced dementia in hospital: a video reflexive ethnography. Citation Text: Dadich A, Rodrigues J, De Bellis A, et al. Patient safety for people experiencing advanced dementia in hospital: a video reflexive ethnography. Dementia (London). 202…

  19. Current pulse: can a production system reduce medical errors in health care? | PSNet

    psnet.ahrq.gov/issue/current-pulse-can-production-system-reduce-medical-errors-health-care
    September 09, 2011 - Commentary Current pulse: can a production system reduce medical errors in health care? Citation Text: Printezis A, Gopalakrishnan M. Current pulse: can a production system reduce medical errors in health care? Qual Manag Health Care. 2007;16(3):226-238. Copy Citation Format: …

  20. General internists in pursuit of diagnostic excellence in primary care: a #ProudtobeGIM thread that unites us all. | PSNet

    psnet.ahrq.gov/issue/general-internists-pursuit-diagnostic-excellence-primary-care-proudtobegim-thread-unites-us
    April 03, 2024 - Commentary General internists in pursuit of diagnostic excellence in primary care: a #ProudtobeGIM thread that unites us all. Citation Text: Kwan JL, Singh H. General Internists in Pursuit of Diagnostic Excellence in Primary Care: a #ProudtobeGIM Thread That Unites Us All. J Gen Intern M…
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