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psnet.ahrq.gov/issue/patterns-opioid-administration-among-opioid-naive-inpatients-and-associations-postdischarge
November 05, 2008 - Study
Patterns of opioid administration among opioid-naive inpatients and associations with postdischarge opioid use: a cohort study.
Citation Text:
Donohue JM, Kennedy JN, Seymour CW, et al. Patterns of Opioid Administration Among Opioid-Naive Inpatients and Associations With Postdischa…
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psnet.ahrq.gov/issue/survey-hospital-quality-improvement-activities
January 27, 2019 - Study
A survey of hospital quality improvement activities.
Citation Text:
Cohen AB, Restuccia JD, Shwartz M, et al. A survey of hospital quality improvement activities. Med Care Res Rev. 2008;65(5):571-95. doi:10.1177/1077558708318285.
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psnet.ahrq.gov/issue/advancing-health-equity-patient-safety-reckoning-challenge-and-opportunity
February 23, 2022 - Commentary
Advancing health equity in patient safety: a reckoning, challenge and opportunity.
Citation Text:
Chin MH. Advancing health equity in patient safety: a reckoning, challenge and opportunity. BMJ Qual Saf. 2021;30(5):356-361. doi:10.1136/bmjqs-2020-012599.
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psnet.ahrq.gov/issue/prevalence-harmful-diagnostic-errors-hospitalised-adults-systematic-review-and-meta-analysis
April 01, 2020 - Review
Emerging Classic
Prevalence of harmful diagnostic errors in hospitalised adults: a systematic review and meta-analysis.
Citation Text:
Gunderson CG, Bilan VP, Holleck JL, et al. Prevalence of harmful diagnostic errors in hospitalised adults: a systematic …
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psnet.ahrq.gov/issue/antidepressant-and-antipsychotic-medication-errors-reported-united-states-poison-control
March 24, 2021 - Study
Antidepressant and antipsychotic medication errors reported to United States poison control centers.
Citation Text:
Kamboj A, Spiller HA, Casavant MJ, et al. Antidepressant and antipsychotic medication errors reported to United States poison control centers. Pharmacoepidemiol Drug …
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psnet.ahrq.gov/issue/how-dangerous-day-hospital-model-adverse-events-and-length-stay-medical-inpatients
February 09, 2012 - Study
Classic
How dangerous is a day in hospital?: A model of adverse events and length of stay for medical inpatients.
Citation Text:
Hauck K, Zhao X. How dangerous is a day in hospital? A model of adverse events and length of stay for medical inpatients. Med…
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psnet.ahrq.gov/issue/state-health-burnout-healthy-behaviors-workplace-wellness-support-and-concerns-medication
July 14, 2021 - Study
The state of health, burnout, healthy behaviors, workplace wellness support, and concerns of medication errors in pharmacists during the COVID-19 pandemic.
Citation Text:
Melnyk BM, Hsieh AP, Tan A, et al. The state of health, burnout, healthy behaviors, workplace wellness support,…
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psnet.ahrq.gov/issue/developing-and-implementing-new-safe-practices-voluntary-adoption-through-statewide
June 13, 2011 - Commentary
Developing and implementing new safe practices: voluntary adoption through statewide collaboratives.
Citation Text:
Leape L, Rogers G, Hanna D, et al. Developing and implementing new safe practices: voluntary adoption through statewide collaboratives. Qual Saf Health Care. 2…
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psnet.ahrq.gov/issue/outcomes-quality-improvement-project-educating-nurses-medication-administration-and-errors
April 24, 2018 - Study
Outcomes of a quality improvement project for educating nurses on medication administration and errors in nursing homes.
Citation Text:
Tenhunen ML, Tanner EK, Dahlen R. Outcomes of a quality improvement project for educating nurses on medication administration and errors in nursin…
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psnet.ahrq.gov/issue/improving-adherence-long-term-opioid-therapy-guidelines-reduce-opioid-misuse-primary-care
January 23, 2019 - Study
Improving adherence to long-term opioid therapy guidelines to reduce opioid misuse in primary care: a cluster-randomized trial.
Citation Text:
Liebschutz JM, Xuan Z, Shanahan CW, et al. Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Ca…
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psnet.ahrq.gov/issue/economic-consequences-medical-injuries-implications-no-fault-insurance-plan
February 18, 2011 - Study
Classic
The economic consequences of medical injuries: implications for a no-fault insurance plan.
Citation Text:
Johnson WG, Brennan TA, Newhouse JP, et al. The economic consequences of medical injuries. Implications for a no-fault insurance plan. JAMA.…
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psnet.ahrq.gov/issue/preventing-medical-injury
February 18, 2011 - Study
Classic
Preventing medical injury.
Citation Text:
Leape LL, Lawthers AG, Brennan TA, et al. Preventing medical injury. QRB - Qual Rev Bull. 1993;19(5):144-149. doi:10.1016/s0097-5990(16)30608-x.
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psnet.ahrq.gov/issue/five-system-barriers-achieving-ultrasafe-health-care
September 29, 2017 - Commentary
Classic
Five system barriers to achieving ultrasafe health care.
Citation Text:
Amalberti R, Auroy Y, Berwick D, et al. Five system barriers to achieving ultrasafe health care. Ann Intern Med. 2005;142(9):756-64.
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psnet.ahrq.gov/issue/system-factors-affecting-intraoperative-risk-and-resilience-applying-novel-integrated
August 25, 2021 - Study
Emerging Classic
System factors affecting intraoperative risk and resilience: applying a novel integrated approach to study surgical performance and patient safety.
Citation Text:
Kolodzey L, Trbovich PL, Kashfi A, et al. System Factors Affecting Intraope…
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psnet.ahrq.gov/issue/house-staff-team-workload-and-organization-effects-patient-outcomes-academic-general-internal
February 24, 2011 - Study
House staff team workload and organization effects on patient outcomes in an academic general internal medicine inpatient service.
Citation Text:
Ong M, Bostrom A, Vidyarthi A, et al. House staff team workload and organization effects on patient outcomes in an academic general in…
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psnet.ahrq.gov/issue/information-transfer-and-communication-surgery-systematic-review
September 26, 2012 - Review
Information transfer and communication in surgery: a systematic review.
Citation Text:
Nagpal K, Vats A, Lamb B, et al. Information transfer and communication in surgery: a systematic review. Ann Surg. 2010;252(2):225-39. doi:10.1097/SLA.0b013e3181e495c2.
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psnet.ahrq.gov/curated-library/diagnostic-error
August 10, 2025 - The majority of the diagnostic errors resulted in some form of clinical impact, including short-term … Missed or delayed diagnoses accounted for 21% of 55,377 claims analyzed, and the majority of these cases … Investigators found that three groups of diagnoses accounted for the majority of closed claims and high-severity
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psnet.ahrq.gov/node/33798/psn-pdf
January 01, 2015 - ineffective strategy for preventing further patient safety mishaps, particularly
considering that the majority … The majority of respondents, in all groups,
endorsed punitive measures such as fines, suspensions, or
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - High-Risk Pregnancy Program links clinicians and
patients across the state with UAMS, where the vast majority … Pregnancy Program links patients and clinicians across the state with the medical center,
where the vast majority … The majority of
referrals continue to be managed locally, but patients with abnormal findings may be … access to consultations: Since the implementation of the High-Risk Pregnancy
Program in 2003, the vast majority … Renewing annually, the program contract dedicates
the majority of funding toward the telemedicine infrastructure
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psnet.ahrq.gov/node/33853/psn-pdf
March 01, 2018 - But it is
disappointing that in the majority of hospitals there has been no change, and some hospitals … A majority of nurses say that they and other staff feel like their mistakes are held against them
and … RW: The majority of nurses in hospitals are working with and through technology.