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  1. Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. | PSNet

    psnet.ahrq.gov/issue/does-root-cause-analysis-improve-patient-safety-systematic-review-department-veterans-affairs
    March 24, 2021 - Review Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Citation Text: Shah F, Falconer EA, Cimiotti JP. Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Qual Manag Healt…

  2. A comprehensive obstetric patient safety program reduces liability claims and payments. | PSNet

    psnet.ahrq.gov/issue/comprehensive-obstetric-patient-safety-program-reduces-liability-claims-and-payments
    June 22, 2017 - Study A comprehensive obstetric patient safety program reduces liability claims and payments. Citation Text: Pettker CM, Thung SF, Lipkind HS, et al. A comprehensive obstetric patient safety program reduces liability claims and payments. Am J Obstet Gynecol. 2014;211(4):319-25. doi:10.10…

  3. Using incident reports to assess communication failures and patient outcomes. | PSNet

    psnet.ahrq.gov/issue/using-incident-reports-assess-communication-failures-and-patient-outcomes
    February 06, 2019 - Study Using incident reports to assess communication failures and patient outcomes. Citation Text: Umberfield E, Ghaferi AA, Krein SL, et al. Using Incident Reports to Assess Communication Failures and Patient Outcomes. Jt Comm J Qual Patient Saf. 2019;45(6):406-413. doi:10.1016/j.jcjq.2…

  4. Delayed time to defibrillation after in-hospital cardiac arrest. | PSNet

    psnet.ahrq.gov/issue/delayed-time-defibrillation-after-hospital-cardiac-arrest
    June 08, 2010 - Study Classic Delayed time to defibrillation after in-hospital cardiac arrest. Citation Text: Chan PS, Krumholz HM, Nichol G, et al. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17. doi:10.1056/NEJMoa0706467. C…

  5. Review of computerized physician handoff tools for improving the quality of patient care. | PSNet

    psnet.ahrq.gov/issue/review-computerized-physician-handoff-tools-improving-quality-patient-care
    September 07, 2011 - Review Review of computerized physician handoff tools for improving the quality of patient care. Citation Text: Li P, Ali S, Tang C, et al. Review of computerized physician handoff tools for improving the quality of patient care. J Hosp Med. 2013;8(8):456-63. doi:10.1002/jhm.1988. C…

  6. Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: a real-time observational study. | PSNet

    psnet.ahrq.gov/issue/organisation-and-characteristics-out-hours-primary-care-during-covid-19-outbreak-real-time
    April 14, 2021 - Study Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: a real-time observational study. Citation Text: Morreel S, Philips H, Verhoeven V. Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: a real-time observa…

  7. Large-scale implementation of the I-PASS handover system at an academic medical centre. | PSNet

    psnet.ahrq.gov/issue/large-scale-implementation-i-pass-handover-system-academic-medical-centre
    March 27, 2018 - Study Large-scale implementation of the I-PASS handover system at an academic medical centre. Citation Text: Shahian DM, McEachern K, Rossi L, et al. Large-scale implementation of the I-PASS handover system at an academic medical centre. BMJ Qual Saf. 2017;26(9):760-770. doi:10.1136/bmjq…

  8. Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective record review studies. | PSNet

    psnet.ahrq.gov/issue/trends-diagnostic-adverse-events-hospital-deaths-longitudinal-analyses-four-retrospective
    May 18, 2022 - Study Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective record review studies. Citation Text: Hooftman J, Zwaan L, Sikkens JJ, et al. Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective reco…

  9. Patient safety from executive hospital management to wards: a qualitative study identifying factors influencing implementation. | PSNet

    psnet.ahrq.gov/issue/patient-safety-executive-hospital-management-wards-qualitative-study-identifying-factors
    March 08, 2023 - Study Patient safety from executive hospital management to wards: a qualitative study identifying factors influencing implementation. Citation Text: Conner T, Unsworth J, Machin A. Patient safety from executive hospital management to wards: a qualitative study identifying factors influen…

  10. Using human factors methods to mitigate bias in artificial intelligence-based clinical decision support. | PSNet

    psnet.ahrq.gov/issue/using-human-factors-methods-mitigate-bias-artificial-intelligence-based-clinical-decision
    July 10, 2019 - Commentary Using human factors methods to mitigate bias in artificial intelligence-based clinical decision support. Citation Text: Militello LG, Diiulio J, Wilson DL, et al. Using human factors methods to mitigate bias in artificial intelligence-based clinical decision support. J Am Med …

  11. Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories. | PSNet

    psnet.ahrq.gov/issue/learning-environments-reliability-enhancing-work-practices-employee-engagement-and-safety
    August 12, 2020 - Study Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories. Citation Text: Gilmartin HM, Hess E, Mueller C, et al. Learning environments, reliability enhancing work practices, employee engagement, …

  12. Linking patient safety climate with missed nursing care in labor and delivery units: findings from the LaborRNs survey. | PSNet

    psnet.ahrq.gov/issue/linking-patient-safety-climate-missed-nursing-care-labor-and-delivery-units-findings-laborrns
    January 19, 2022 - Study Linking patient safety climate with missed nursing care in labor and delivery units: findings from the LaborRNs survey. Citation Text: Zhong J, Simpson KR, Spetz J, et al. Linking patient safety climate with missed nursing care in labor and delivery units: findings from the LaborRN…

  13. Promoting patient and nurse safety: testing a behavioural health intervention in a learning healthcare system: results of the DEMEANOR pragmatic, cluster, cross-over trial. | PSNet

    psnet.ahrq.gov/issue/promoting-patient-and-nurse-safety-testing-behavioural-health-intervention-learning
    May 04, 2022 - Study Promoting patient and nurse safety: testing a behavioural health intervention in a learning healthcare system: results of the DEMEANOR pragmatic, cluster, cross-over trial. Citation Text: Hasselblad M, Morrison J, Kleinpell R, et al. Promoting patient and nurse safety: testing a be…

  14. Designing an intervention to improve medication safety for nursing home residents based on experiential knowledge related to patient safety culture at the nursing home front line: cocreative process study. | PSNet

    psnet.ahrq.gov/issue/designing-intervention-improve-medication-safety-nursing-home-residents-based-experiential
    February 14, 2024 - Commentary Designing an intervention to improve medication safety for nursing home residents based on experiential knowledge related to patient safety culture at the nursing home front line: cocreative process study. Citation Text: Juhl MH, Soerensen AL, Vardinghus-Nielsen H, et al. Desi…

  15. Older patients' engagement in hospital medication safety behaviours. | PSNet

    psnet.ahrq.gov/issue/older-patients-engagement-hospital-medication-safety-behaviours
    November 17, 2021 - Study Older patients' engagement in hospital medication safety behaviours. Citation Text: Tobiano G, Chaboyer W, Dornan G, et al. Older patients’ engagement in hospital medication safety behaviours. Aging Clin Exp Res. 2021;33(12):3353-3361. doi:10.1007/s40520-021-01866-3. Copy Citatio…

  16. The influence of COVID-19 visitation restrictions on patient experience and safety outcomes: a critical role for subjective advocates. | PSNet

    psnet.ahrq.gov/issue/influence-covid-19-visitation-restrictions-patient-experience-and-safety-outcomes-critical
    July 14, 2021 - Study The influence of COVID-19 visitation restrictions on patient experience and safety outcomes: a critical role for subjective advocates. Citation Text: Silvera GA, Wolf JA, Stanowski A, et al. The influence of COVID-19 visitation restrictions on patient experience and safety outcomes…

  17. Toward safer opioid prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial. | PSNet

    psnet.ahrq.gov/issue/toward-safer-opioid-prescribing-hiv-care-tower-mixed-methods-cluster-randomized-trial
    September 07, 2022 - Study Toward safer opioid prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial. Citation Text: Cedillo G, George MC, Deshpande R, et al. Toward safer opioid prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial. Addict Sci Clin Pract. 2022;17(1)…

  18. Adverse events and emergency department opioid prescriptions in adolescents. | PSNet

    psnet.ahrq.gov/issue/adverse-events-and-emergency-department-opioid-prescriptions-adolescents
    December 21, 2022 - Study Adverse events and emergency department opioid prescriptions in adolescents. Citation Text: Worsham CM, Woo J, Jena AB, et al. Adverse events and emergency department opioid prescriptions in adolescents. Health Aff (Millwood). 2021;40(6):970-978. doi:10.1377/hlthaff.2020.01762. C…

  19. The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: a systematic review. | PSNet

    psnet.ahrq.gov/issue/impact-introducing-automated-dispensing-cabinets-barcode-medication-administration-and-closed
    March 10, 2021 - Review Emerging Classic The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: a systematic review. C…

  20. Enhancing patient safety and risk management through clinical pathways in oncology. | PSNet

    psnet.ahrq.gov/issue/enhancing-patient-safety-and-risk-management-through-clinical-pathways-oncology
    September 13, 2023 - Study Enhancing patient safety and risk management through clinical pathways in oncology. Citation Text: Milanesi M, Fiorito R, Caloccia L, et al. Enhancing patient safety and risk management through clinical pathways in oncology. BMJ Open Qual. 2025;14(1):e003012. doi:10.1136/bmjoq-2024…
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