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Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. | PSNet

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February 18, 2011 - Study Classic Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. Citation Text: Brennan TA, Leape LL, Laird NM, et al. Incidence of Adverse Events and Negligence in Hospitalized Patients. N Eng…

Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance. | PSNet

psnet.ahrq.gov/issue/improving-hand-hygiene-eight-hospitals-united-states-targeting-specific-causes-noncompliance

April 13, 2022 - Study Classic Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance. Citation Text: Chassin MR, Mayer C, Nether K. Improving hand hygiene at eight hospitals in the United States by targeting specific causes …

Individual characteristics that promote or prevent psychological safety and error reporting in healthcare: a systematic review. | PSNet

psnet.ahrq.gov/issue/individual-characteristics-promote-or-prevent-psychological-safety-and-error-reporting

September 14, 2022 - Review Individual characteristics that promote or prevent psychological safety and error reporting in healthcare: a systematic review. Citation Text: Wawersik DM, Boutin ER, Gore T, et al. Individual characteristics that promote or prevent psychological safety and error reporting in heal…

Leveraging artificial intelligence to reduce diagnostic errors in emergency medicine: challenges, opportunities, and future directions. | PSNet

psnet.ahrq.gov/issue/leveraging-artificial-intelligence-reduce-diagnostic-errors-emergency-medicine-challenges

May 29, 2019 - Commentary Leveraging artificial intelligence to reduce diagnostic errors in emergency medicine: challenges, opportunities, and future directions. Citation Text: Taylor RA, Sangal RB, Smith ME, et al. Leveraging artificial intelligence to reduce diagnostic errors in emergency medicine: c…

Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations. | PSNet

psnet.ahrq.gov/issue/mind-gap-between-recommendation-and-implementation-principles-and-lessons-aftermath-incident

March 11, 2020 - Study Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations. Citation Text: Wrigstad J, Bergström J, Gusta…

Cost–benefit analysis of a support program for nursing staff. | PSNet

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October 26, 2016 - Study Classic Cost–benefit analysis of a support program for nursing staff. Citation Text: Moran D, Wu AW, Connors C, et al. Cost-Benefit Analysis of a Support Program for Nursing Staff. J Patient Saf. 2020;16(4):e250-e254. doi:10.1097/pts.0000000000000376. Co…

To Err Is Human: Building a Safer Health System. | PSNet

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July 08, 2016 - Book/Report Classic To Err Is Human: Building a Safer Health System. Citation Text: To Err Is Human: Building a Safer Health System. Kohn KT, Corrigan JM, Donaldson MS, eds. Washington, DC: Committee on Quality Health Care in America, Institute of Medicine: Nati…

Application of a digital quality measure for cancer diagnosis in Epic Cosmos. | PSNet

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November 13, 2024 - Study Application of a digital quality measure for cancer diagnosis in Epic Cosmos. Citation Text: Zimolzak AJ, Khan SP, Singh H, et al. Application of a digital quality measure for cancer diagnosis in Epic Cosmos. J Am Med Inform Assoc. 2025;32(1):227-229. doi:10.1093/jamia/ocae253. C…

Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action. | PSNet

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October 28, 2020 - Review Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action. Citation Text: Gleason KT, Davidson PM, Tanner EK, et al. Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to act…

Encouraging patients to speak up about problems in cancer care. | PSNet

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March 11, 2013 - Study Encouraging patients to speak up about problems in cancer care. Citation Text: Mazor KM, Kamineni A, Roblin DW, et al. Encouraging patients to speak up about problems in cancer care. J Patient Saf. 2021;17(8):e1278-e1284. doi:10.1097/pts.0000000000000510. Copy Citation Format…

Adverse-event-reporting practices by US hospitals: results of a national survey. | PSNet

psnet.ahrq.gov/issue/adverse-event-reporting-practices-us-hospitals-results-national-survey

December 30, 2014 - Study Adverse-event-reporting practices by US hospitals: results of a national survey. Citation Text: Farley DO, Haviland A, Champagne S, et al. Adverse-event-reporting practices by US hospitals: results of a national survey. Qual Saf Health Care. 2008;17(6):416-23. doi:10.1136/qshc.20…

Effectiveness and efficiency of root cause analysis in medicine. | PSNet

psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine

July 11, 2012 - Commentary Classic Effectiveness and efficiency of root cause analysis in medicine. Citation Text: Wu AW. Effectiveness and Efficiency of Root Cause Analysis in Medicine. JAMA. 2008;299(6):685-687. doi:10.1001/jama.299.6.685. Copy Citation Format: …

Nurses’ perspectives on the impact of management approaches on the blame culture in health-care organizations. | PSNet

psnet.ahrq.gov/issue/nurses-perspectives-impact-management-approaches-blame-culture-health-care-organizations

September 02, 2020 - Study Nurses’ perspectives on the impact of management approaches on the blame culture in health-care organizations. Citation Text: Okpala P. Nurses’ perspectives on the impact of management approaches on the blame culture in health-care organizations. Int J Healthc Manage. 2020;13(sup1)…

Medication errors among adults and children with cancer in the outpatient setting. | PSNet

psnet.ahrq.gov/issue/medication-errors-among-adults-and-children-cancer-outpatient-setting

January 16, 2010 - Study Medication errors among adults and children with cancer in the outpatient setting. Citation Text: Walsh KE, Dodd KS, Seetharaman K, et al. Medication errors among adults and children with cancer in the outpatient setting. J Clin Oncol. 2009;27(6):891-6. doi:10.1200/JCO.2008.18.60…

Measuring harm in health care: optimizing adverse event review. | PSNet

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May 15, 2013 - Study Measuring harm in health care: optimizing adverse event review. Citation Text: Walsh KE, Harik P, Mazor KM, et al. Measuring Harm in Health Care: Optimizing Adverse Event Review. Med Care. 2017;55(4):436-441. doi:10.1097/MLR.0000000000000679. Copy Citation Format: DOI…

Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education. | PSNet

psnet.ahrq.gov/issue/root-cause-analysis-and-actions-prevention-medical-errors-quality-improvement-and-resident

October 19, 2016 - Commentary Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education. Citation Text: Charles R, Hood B, DeRosier JM, et al. Root Cause Analysis and Actions for the Prevention of Medical Errors: Quality Improvement and Resident Educat…

Improving the quality of insulin prescribing for people with diabetes being discharged from hospital | PSNet

psnet.ahrq.gov/issue/improving-quality-insulin-prescribing-people-diabetes-being-discharged-hospital

November 16, 2022 - Journal Article Improving the quality of insulin prescribing for people with diabetes being discharged from hospital Citation Text: Bain A, Silcock J, Kavanagh S, et al. Improving the quality of insulin prescribing for people with diabetes being discharged from hospital. BMJ Open Qual. 2…

Triggers contributing to health care clinicians' disruptive behaviors. | PSNet

psnet.ahrq.gov/issue/triggers-contributing-health-care-clinicians-disruptive-behaviors

June 24, 2020 - Study Triggers contributing to health care clinicians' disruptive behaviors. Citation Text: Bae S-H, Dang D, Karlowicz KA, et al. Triggers contributing to health care clinicians' disruptive behaviors. J Patient Saf. 2020;16(3):e148-e155. doi:10.1097/pts.0000000000000288. Copy Citation …

Long-term care nurses' experiences with patient safety incident management: a qualitative study. | PSNet

psnet.ahrq.gov/issue/long-term-care-nurses-experiences-patient-safety-incident-management-qualitative-study

March 24, 2021 - Study Long-term care nurses' experiences with patient safety incident management: a qualitative study. Citation Text: Serre N, Espin S, Indar A, et al. Long-term care nurses' experiences with patient safety incident management: a qualitative study. J Nurs Care Qual. 2022;37(2):188-194. d…

Safety and risk management interventions in hospitals: a systematic review of the literature. | PSNet

psnet.ahrq.gov/issue/safety-and-risk-management-interventions-hospitals-systematic-review-literature

April 01, 2010 - Review Safety and risk management interventions in hospitals: a systematic review of the literature. Citation Text: Dückers M, Faber M, Cruijsberg J, et al. Safety and risk management interventions in hospitals: a systematic review of the literature. Med Care Res Rev. 2009;66(6 Suppl):…

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