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  1. An assessment of basic patient safety skills in residents entering the first year of clinical training. | PSNet

    psnet.ahrq.gov/issue/assessment-basic-patient-safety-skills-residents-entering-first-year-clinical-training
    February 21, 2018 - Study An assessment of basic patient safety skills in residents entering the first year of clinical training. Citation Text: Comunale ME, Sandoval M, Broussard LT. An Assessment of Basic Patient Safety Skills in Residents Entering the First Year of Clinical Training. J Patient Saf. 2018;…

  2. Analysis of paediatric long-term ventilation incidents in the community | PSNet

    psnet.ahrq.gov/issue/analysis-paediatric-long-term-ventilation-incidents-community
    November 06, 2024 - Study Analysis of paediatric long-term ventilation incidents in the community Citation Text: Nawaz RF, Page B, Harrop E, et al. Analysis of paediatric long-term ventilation incidents in the community. Arch Dis Child. 2020;105(5):446-451. doi:10.1136/archdischild-2019-317965. Copy Citat…

  3. Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st century. | PSNet

    psnet.ahrq.gov/issue/shepherding-change-how-market-healthcare-providers-and-public-policy-can-deliver-quality-care
    July 20, 2022 - Commentary Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st century. Citation Text: Kennedy P, Pronovost P. Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st…

  4. Use of nondisclosure agreements in medical malpractice settlements by a large academic health care system. | PSNet

    psnet.ahrq.gov/issue/use-nondisclosure-agreements-medical-malpractice-settlements-large-academic-health-care
    December 19, 2018 - Study Use of nondisclosure agreements in medical malpractice settlements by a large academic health care system. Citation Text: Sage WM, Jablonski JS, Thomas EJ. Use of Nondisclosure Agreements in Medical Malpractice Settlements by a Large Academic Health Care System. JAMA Intern Med. 20…

  5. Impact of sample size on variation of adverse events and preventable adverse events: systematic review on epidemiology and contributing factors. | PSNet

    psnet.ahrq.gov/issue/impact-sample-size-variation-adverse-events-and-preventable-adverse-events-systematic-review
    May 15, 2024 - Review Impact of sample size on variation of adverse events and preventable adverse events: systematic review on epidemiology and contributing factors. Citation Text: Lessing C, Schmitz A, Albers B, et al. Impact of sample size on variation of adverse events and preventable adverse eve…

  6. A medication error prevention survey: five years of results. | PSNet

    psnet.ahrq.gov/issue/medication-error-prevention-survey-five-years-results
    March 26, 2015 - Study A medication error prevention survey: five years of results. Citation Text: Cusano FL, Chambers C, Summach L. A medication error prevention survey: five years of results. J Oncol Pharm Pract. 2009;15(2):87-93. doi:10.1177/1078155208099284. Copy Citation Format: DOI …

  7. Moral distress in intensive care unit personnel is not consistently associated with adverse medication events and other adverse events | PSNet

    psnet.ahrq.gov/issue/moral-distress-intensive-care-unit-personnel-not-consistently-associated-adverse-medication
    November 02, 2010 - Study Moral distress in intensive care unit personnel is not consistently associated with adverse medication events and other adverse events Citation Text: Dodek P, Norena M, Ayas N, et al. Moral distress in intensive care unit personnel is not consistently associated with adverse medica…

  8. Influences of physical layout and space on patient safety and communication in ambulatory oncology practices: a multisite, mixed method investigation. | PSNet

    psnet.ahrq.gov/issue/influences-physical-layout-and-space-patient-safety-and-communication-ambulatory-oncology
    August 25, 2021 - Study Influences of physical layout and space on patient safety and communication in ambulatory oncology practices: a multisite, mixed method investigation. Citation Text: Fauer AJ. Influences of physical layout and space on patient safety and communication in ambulatory oncology practic…

  9. Inappropriate dosing of direct oral anticoagulants in patients with atrial fibrillation. | PSNet

    psnet.ahrq.gov/issue/inappropriate-dosing-direct-oral-anticoagulants-patients-atrial-fibrillation
    August 04, 2021 - Study Emerging Classic Inappropriate dosing of direct oral anticoagulants in patients with atrial fibrillation. Citation Text: Sugrue A, Sanborn D, Amin M, et al. Inappropriate dosing of direct oral anticoagulants in patients with atrial fibrillation. Am J Cardi…

  10. Leadership and the high reliability transformation: a qualitative study at Truman VA medical center. | PSNet

    psnet.ahrq.gov/issue/leadership-and-high-reliability-transformation-qualitative-study-truman-va-medical-center
    May 31, 2023 - Study Leadership and the high reliability transformation: a qualitative study at Truman VA medical center. Citation Text: Leonard C, Gilmartin HM, Starr LM, et al. Leadership and the high reliability transformation: a qualitative study at Truman VA medical center. J Healthc Risk Manag. 2…

  11. Association of hospital public quality reporting with electronic health record medication safety performance. | PSNet

    psnet.ahrq.gov/issue/association-hospital-public-quality-reporting-electronic-health-record-medication-safety
    October 21, 2020 - Study Association of hospital public quality reporting with electronic health record medication safety performance. Citation Text: Holmgren AJ, Bates DW. Association of hospital public quality reporting with electronic health record medication safety performance. JAMA Netw Open. 2021;4(9…

  12. Clinical oversight: conceptualizing the relationship between supervision and safety. | PSNet

    psnet.ahrq.gov/issue/clinical-oversight-conceptualizing-relationship-between-supervision-and-safety
    June 23, 2010 - Study Clinical oversight: conceptualizing the relationship between supervision and safety. Citation Text: Kennedy TJT, Lingard LA, Baker R, et al. Clinical oversight: conceptualizing the relationship between supervision and safety. J Gen Intern Med. 2007;22(8):1080-5. Copy Citation …

  13. An organization-specific and modifiable inpatient safety composite measure. | PSNet

    psnet.ahrq.gov/issue/organization-specific-and-modifiable-inpatient-safety-composite-measure
    June 14, 2023 - Commentary An organization-specific and modifiable inpatient safety composite measure. Citation Text: Smith PK, Amster A. An Organization-Specific and Modifiable Inpatient Safety Composite Measure. Jt Comm J Qual Patient Saf. 2019;45(4):304-314. doi:10.1016/j.jcjq.2018.11.005. Copy Cit…

  14. Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study. | PSNet

    psnet.ahrq.gov/issue/discrepancies-written-versus-calculated-durations-opioid-prescriptions-pre-post-study
    October 19, 2022 - Study Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study. Citation Text: Slovis BH, Kairys J, Babula B, et al. Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study. JMIR Med Inform. 2020;8(3). doi:10.2196/1…

  15. Unplanned return to theater: a quality of care and risk management index? | PSNet

    psnet.ahrq.gov/issue/unplanned-return-theater-quality-care-and-risk-management-index
    August 20, 2018 - Study Unplanned return to theater: a quality of care and risk management index? Citation Text: Pujol N, Merrer J, Lemaire B, et al. Unplanned return to theater: A quality of care and risk management index? Orthop Traumatol Surg Res. 2015;101(4):399-403. doi:10.1016/j.otsr.2015.03.013. …

  16. Internal reporting system to improve a pharmacy's medication distribution process. | PSNet

    psnet.ahrq.gov/issue/internal-reporting-system-improve-pharmacys-medication-distribution-process
    October 31, 2017 - Study Internal reporting system to improve a pharmacy's medication distribution process. Citation Text: Rickrode GA, Williams-Lowe ME, Rippe JL, et al. Internal reporting system to improve a pharmacy's medication distribution process. Am J Health Syst Pharm. 2007;64(11):1197-202. Cop…

  17. Efficacy of an incident-reporting system in cellular pathology: a practical experience. | PSNet

    psnet.ahrq.gov/issue/efficacy-incident-reporting-system-cellular-pathology-practical-experience
    August 21, 2024 - Study Efficacy of an incident-reporting system in cellular pathology: a practical experience. Citation Text: Rakha EA, Clark D, Chohan BS, et al. Efficacy of an incident-reporting system in cellular pathology: a practical experience. J Clin Pathol. 2012;65(7):643-8. doi:10.1136/jclinpa…

  18. A systems approach to evaluating ionizing radiation: six focus areas to improve quality, efficiency, and patient safety. | PSNet

    psnet.ahrq.gov/issue/systems-approach-evaluating-ionizing-radiation-six-focus-areas-improve-quality-efficiency-and
    March 14, 2016 - Commentary A systems approach to evaluating ionizing radiation: six focus areas to improve quality, efficiency, and patient safety. Citation Text: Perlin JB, Mower L, Bushe C. A systems approach to evaluating ionizing radiation: six focus areas to improve quality, efficiency, and patient…

  19. Human error and the problem of causality in analysis of accidents. | PSNet

    psnet.ahrq.gov/issue/human-error-and-problem-causality-analysis-accidents
    August 25, 2021 - Commentary Classic Human error and the problem of causality in analysis of accidents. Citation Text: Rasmussen J. Human error and the problem of causality in analysis of accidents. Philos Trans R Soc Lond B Biol Sci. 1990;327(1241):449-462. Copy Citation …

  20. Medical errors and quality of care: from control to commitment. | PSNet

    psnet.ahrq.gov/issue/medical-errors-and-quality-care-control-commitment
    July 15, 2020 - Commentary Medical errors and quality of care: from control to commitment. Citation Text: Khatri N, Baveja A, Boren SA, et al. Medical Errors and Quality of Care: From Control to Commitment. California Manage Review. 2006;48(3):115-141. doi:10.2307/41166353. Copy Citation Format…
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