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  1. Re-examining high reliability: actively organising for safety. | PSNet

    psnet.ahrq.gov/issue/re-examining-high-reliability-actively-organising-safety
    October 13, 2018 - Commentary Re-examining high reliability: actively organising for safety. Citation Text: Sutcliffe K, Paine LA, Pronovost P. Re-examining high reliability: actively organising for safety. BMJ Qual Saf. 2017;26(3):248-251. doi:10.1136/bmjqs-2015-004698. Copy Citation Format: …

  2. Medication complexity, medication number, and their relationships to medication discrepancies. | PSNet

    psnet.ahrq.gov/issue/medication-complexity-medication-number-and-their-relationships-medication-discrepancies
    November 16, 2022 - Study Medication complexity, medication number, and their relationships to medication discrepancies. Citation Text: Patel CH, Zimmerman KM, Fonda JR, et al. Medication Complexity, Medication Number, and Their Relationships to Medication Discrepancies. Ann Pharmacother. 2016;50(7):534-40.…

  3. Digitizing diagnosis: a review of mobile applications in the diagnostic process. | PSNet

    psnet.ahrq.gov/issue/digitizing-diagnosis-review-mobile-applications-diagnostic-process
    October 10, 2018 - Study Digitizing diagnosis: a review of mobile applications in the diagnostic process. Citation Text: Jutel A, Lupton D. Digitizing diagnosis: a review of mobile applications in the diagnostic process. Diagnosis (Berl). 2015;2(2):89-96. doi:10.1515/dx-2014-0068. Copy Citation Forma…

  4. Potential Solutions to Lab Data Extraction (pdf file)

    hcup-us.ahrq.gov/datainnovations/clinicalcontentenhancementtoolkit/ny8.pdf
    April 29, 2014 - Potential Solutions to Lab Data Extraction 1 Potential Solutions to Lab Data Extraction DATA SELECTION STEP POTENTIAL DIFFICULTIES POTENTIAL SOLUTIONS 1 DOH will send the lab a list of patients, identified by Medical Record Number (MRN) and Patient Control Number (also called Encounter Number),…

  5. 'Safe enough in here?': Patients' expectations and experiences of feeling safe in an acute psychiatric inpatient ward. | PSNet

    psnet.ahrq.gov/issue/safe-enough-here-patients-expectations-and-experiences-feeling-safe-acute-psychiatric
    January 23, 2017 - Study 'Safe enough in here?': Patients' expectations and experiences of feeling safe in an acute psychiatric inpatient ward. Citation Text: Stenhouse RC. 'Safe enough in here?': patients' expectations and experiences of feeling safe in an acute psychiatric inpatient ward. J Clin Nurs. 20…

  6. Causes of use errors in ventilation devices--systematic review. | PSNet

    psnet.ahrq.gov/issue/causes-use-errors-ventilation-devices-systematic-review
    October 12, 2022 - Review Causes of use errors in ventilation devices--systematic review. Citation Text: Coldewey B, Diruf A, Röhrig R, et al. Causes of use errors in ventilation devices - systematic review. Appl Ergon. 2021;98:103544. doi:10.1016/j.apergo.2021.103544. Copy Citation Format: D…

  7. Towards international consensus on patient harm: perspectives on pressure injury policy. | PSNet

    psnet.ahrq.gov/issue/towards-international-consensus-patient-harm-perspectives-pressure-injury-policy
    September 27, 2016 - Review Towards international consensus on patient harm: perspectives on pressure injury policy. Citation Text: Jackson D, Hutchinson M, Barnason S, et al. Towards international consensus on patient harm: perspectives on pressure injury policy. J Nurs Manag. 2016;24(7):902-914. doi:10.111…

  8. Monitoring and reducing central line-associated bloodstream infections: a national survey of state hospital associations. | PSNet

    psnet.ahrq.gov/issue/monitoring-and-reducing-central-line-associated-bloodstream-infections-national-survey-state
    December 01, 2010 - Study Monitoring and reducing central line-associated bloodstream infections: a national survey of state hospital associations. Citation Text: Murphy DJ, Needham DM, Goeschel CA, et al. Monitoring and reducing central line-associated bloodstream infections: a national survey of state h…

  9. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. | PSNet

    psnet.ahrq.gov/issue/implementation-surgical-comprehensive-unit-based-safety-program-reduce-surgical-site
    November 21, 2017 - Study Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. Citation Text: Wick EC, Hobson DB, Bennett JL, et al. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. J Am Coll Surg. …

  10. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. | PSNet

    psnet.ahrq.gov/issue/using-six-sigma-reduce-medication-errors-home-delivery-pharmacy-service
    November 18, 2015 - Study Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Citation Text: Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24. Copy Citation …

  11. How U.S. teams advanced communication and resolution program adoption at local, state and national levels. | PSNet

    psnet.ahrq.gov/issue/how-us-teams-advanced-communication-and-resolution-program-adoption-local-state-and-national
    April 24, 2018 - Study How U.S. teams advanced communication and resolution program adoption at local, state and national levels. Citation Text: LeCraw FR, Stearns SC, McCoy MJ. How U.S. Teams advanced communication and resolution program adoption at local, state and national levels. J Patient Saf Risk M…

  12. Medication reconciliation in a community pharmacy setting. | PSNet

    psnet.ahrq.gov/issue/medication-reconciliation-community-pharmacy-setting
    November 16, 2022 - Study Medication reconciliation in a community pharmacy setting. Citation Text: Johnson CM, Marcy TR, Harrison DL, et al. Medication reconciliation in a community pharmacy setting. J Am Pharm Assoc (2003). 2010;50(4):523-6. doi:10.1331/JAPhA.2010.09121. Copy Citation Format: …

  13. Enabling Health Care Decisionmaking through the Use of Health Information Technology - 2011 | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/enabling-health-care-decisionmaking-through-use-health-information-technology/annual-summary/2011
    January 01, 2011 - Enabling Health Care Decisionmaking through the Use of Health Information Technology - 2011 Project Name Enabling Health Care Decisionmaking through the Use of Health Information Technology Principal Investigator Lobach, David Organization Duke University Contract Num…

  14. How to perform a root cause analysis for workup and future prevention of medical errors: a review. | PSNet

    psnet.ahrq.gov/issue/how-perform-root-cause-analysis-workup-and-future-prevention-medical-errors-review
    August 03, 2017 - Review How to perform a root cause analysis for workup and future prevention of medical errors: a review. Citation Text: Charles R, Hood B, DeRosier JM, et al. How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient Saf Surg. 2016;10:20.…

  15. Evaluation of a computerized clinical decision support system and EHR-linked registry to improve management of hypertension in community-based health centers - 2010 | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/evaluation-computerized-clinical-decision-support-system-and-electronic-health/annual-summary/2010
    January 01, 2010 - Evaluation of a computerized clinical decision support system and EHR-linked registry to improve management of hypertension in community-based health centers - 2010 Project Name Evaluation of a Computerized Clinical Decision Support System and Electronic Health Record (EHR)-linked Registry to Improv…

  16. The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap. | PSNet

    psnet.ahrq.gov/issue/patient-safety-adoption-framework-practical-framework-bridge-know-do-gap
    May 26, 2021 - Commentary The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap. Citation Text: The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap. Moyal-Smith R, Margo J, Maloney FL, et al. J Patient Saf. 2023;19(4):243-248. Copy…

  17. With money at risk, hospitals push staff to wash hands. | PSNet

    psnet.ahrq.gov/issue/money-risk-hospitals-push-staff-wash-hands
    May 18, 2022 - Newspaper/Magazine Article With money at risk, hospitals push staff to wash hands. Citation Text: Armellino D, Hussain E, Schilling ME, et al. Using High-Technology to Enforce Low-Technology Safety Measures: The Use of Third-party Remote Video Auditing and Real-time Feedback in Health…

  18. Hospital commitments to address diagnostic errors: an assessment of 95 US hospitals. | PSNet

    psnet.ahrq.gov/issue/hospital-commitments-address-diagnostic-errors-assessment-95-us-hospitals
    September 18, 2024 - Study Hospital commitments to address diagnostic errors: an assessment of 95 US hospitals. Citation Text: Campione Russo A, Tilly J‐L, Kaufman L, et al. Hospital commitments to address diagnostic errors: an assessment of 95 US hospitals. J Hosp Med. 2025;20(2):120-134. doi:10.1002/jhm.13…

  19. The influence of context on the effectiveness of hospital quality improvement strategies: a review of systematic reviews. | PSNet

    psnet.ahrq.gov/issue/influence-context-effectiveness-hospital-quality-improvement-strategies-review-systematic
    May 26, 2014 - Review The influence of context on the effectiveness of hospital quality improvement strategies: a review of systematic reviews. Citation Text: Kringos DS, Suñol R, Wagner C, et al. The influence of context on the effectiveness of hospital quality improvement strategies: a review of syst…

  20. Exclusion of residents from surgery-intensive care team communication: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/exclusion-residents-surgery-intensive-care-team-communication-qualitative-study
    December 04, 2015 - Study Exclusion of residents from surgery-intensive care team communication: a qualitative study. Citation Text: Conn LG, Haas B, Rubenfeld GD, et al. Exclusion of Residents From Surgery-Intensive Care Team Communication: A Qualitative Study. J Surg Educ. 2016;73(4):639-47. doi:10.1016/j…
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