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Using FDA reports to inform a classification for health information technology safety problems. | PSNet

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November 03, 2015 - Study Using FDA reports to inform a classification for health information technology safety problems. Citation Text: Magrabi F, Ong M-S, Runciman WB, et al. Using FDA reports to inform a classification for health information technology safety problems. J Am Med Inform Assoc. 2012;19(1):4…

A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. | PSNet

psnet.ahrq.gov/issue/visual-medication-schedule-improve-anticoagulation-control-randomized-controlled-trial

October 21, 2010 - Study A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. Citation Text: Machtinger EL, Wang F, Chen L-L, et al. A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. Jt Comm J Qual Patient Saf. 2007;…

6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. | PSNet

psnet.ahrq.gov/issue/6-pack-programme-decrease-fall-injuries-acute-hospitals-cluster-randomised-controlled-trial

December 21, 2014 - Study Classic 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. Citation Text: Barker AL, Morello RT, Wolfe R, et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled t…

The impact of the use of employee functional flexibility on patient safety. | PSNet

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January 12, 2022 - Study The impact of the use of employee functional flexibility on patient safety. Citation Text: Salvador RO, Gnanlet A, McDermott C. The impact of the use of employee functional flexibility on patient safety. Personnel Rev. 2020;50(3):971-984. doi:10.1108/pr-10-2019-0562. Copy Citatio…

Using the Targeted Solutions Tool to improve hand hygiene compliance is associated with decreased health care–associated infections. | PSNet

psnet.ahrq.gov/issue/using-targeted-solutions-tool-improve-hand-hygiene-compliance-associated-decreased-health

August 18, 2021 - Study Using the Targeted Solutions Tool to improve hand hygiene compliance is associated with decreased health care–associated infections. Citation Text: Shabot M, Chassin MR, France A-C, et al. Using the Targeted Solutions Tool® to Improve Hand Hygiene Compliance Is Associated with Decr…

Analysis of variation between diagnosis at admission vs discharge and clinical outcomes among adults with possible bacteremia. | PSNet

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June 22, 2022 - Study Analysis of variation between diagnosis at admission vs discharge and clinical outcomes among adults with possible bacteremia. Citation Text: Dregmans E, Kaal AG, Meziyerh S, et al. Analysis of variation between diagnosis at admission vs discharge and clinical outcomes among adults…

COVID-19 Pandemic Impact on Healthcare Associated Conditions | PSNet

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November 10, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed COVID-19 Pandemic Impact on Healthcare Associated Conditions Download Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Sam W…

Creating highly reliable health care: how reliability-enhancing work practices affect patient safety in hospitals. | PSNet

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January 12, 2022 - Study Creating highly reliable health care: how reliability-enhancing work practices affect patient safety in hospitals. Citation Text: Vogus TJ, Iacobucci D. Creating Highly Reliable Health Care. ILR Review. 2016;69(4). doi:10.1177/0019793916642759. Copy Citation Format: D…

High-risk medication errors: insight from the UK National Reporting and Learning System. | PSNet

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January 12, 2022 - Study High-risk medication errors: insight from the UK National Reporting and Learning System. Citation Text: Alrowily A, Alfaraidy K, Almutairi S, et al. High-risk medication errors: Insight from the UK National Reporting and learning system. Explor Res Clin Soc Pharm. 2025;17:100531. d…

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…

Multidisciplinary approaches to reducing error and risk in a patient care setting. | PSNet

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January 05, 2017 - Study Classic Multidisciplinary approaches to reducing error and risk in a patient care setting. Citation Text: Connor M, Ponte PR, Conway JB. Multidisciplinary approaches to reducing error and risk in a patient care setting. Crit Care Nurs Clin North Am. 2002…

Failure to rescue female patients undergoing high-risk surgery. | PSNet

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October 25, 2017 - Study Failure to rescue female patients undergoing high-risk surgery. Citation Text: Wagner CM, Joynt Maddox KE, Ailawadi G, et al. Failure to rescue female patients undergoing high-risk surgery. JAMA Surg. 2024;160(1):29-36. doi:10.1001/jamasurg.2024.4574. Copy Citation Format: …

How do we know when we have done enough? Ensuring sufficient patient notification efforts after a large-scale adverse event. | PSNet

psnet.ahrq.gov/issue/how-do-we-know-when-we-have-done-enough-ensuring-sufficient-patient-notification-efforts

August 18, 2021 - Commentary How do we know when we have done enough? Ensuring sufficient patient notification efforts after a large-scale adverse event. Citation Text: Alfandre D, Foglia MB, Holodniy M, et al. How do we know when we have done enough? Ensuring sufficient patient notification efforts after…

Organizational learning: health care leaders need to design structures and processes that enhance collective learning. | PSNet

psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance

November 18, 2020 - Commentary Organizational learning: health care leaders need to design structures and processes that enhance collective learning. Citation Text: Bohmer RM, Edmondson AC. Organizational learning in health care. Health Forum J. 2001;44(2):32-35. Copy Citation Format: Google…

The influence of organizational culture, climate and commitment on speaking up about medical errors. | PSNet

psnet.ahrq.gov/issue/influence-organizational-culture-climate-and-commitment-speaking-about-medical-errors

December 31, 2018 - Study Emerging Classic The influence of organizational culture, climate and commitment on speaking up about medical errors. Citation Text: Levine KJ, Carmody M, Silk KJ. The influence of organizational culture, climate and commitment on speaking up about medical…

Nurses' experiences of organizational learning. | PSNet

psnet.ahrq.gov/issue/nurses-experiences-organizational-learning

July 21, 2021 - Study Nurses' experiences of organizational learning. Citation Text: Lyman B, Biddulph ME, Hopper VG, et al. Nurses' experiences of organisational learning: a qualitative descriptive study. J Nurs Manag. 2020;28(6):1241-1249. doi:10.1111/jonm.13070. Copy Citation Format: DO…

Using Lean to improve medication administration safety: in search of the "perfect dose." | PSNet

psnet.ahrq.gov/issue/using-lean-improve-medication-administration-safety-search-perfect-dose

September 16, 2015 - Study Using Lean to improve medication administration safety: in search of the "perfect dose." Citation Text: Ching JM, Long C, Williams BL, et al. Using lean to improve medication administration safety: in search of the "perfect dose". Jt Comm J Qual Patient Saf. 2013;39(5):195-204. C…

The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. | PSNet

psnet.ahrq.gov/issue/multitasking-clinician-decision-making-and-cognitive-demand-during-and-after-team-handoffs

September 15, 2011 - Study The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. Citation Text: Laxmisan A, Hakimzada F, Sayan OR, et al. The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency c…

Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety. | PSNet

psnet.ahrq.gov/issue/patient-centered-insights-using-health-care-complaints-reveal-hot-spots-and-blind-spots

November 29, 2023 - Study Emerging Classic Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety. Citation Text: Gillespie A, Reader TW. Patient-Centered Insights: Using Health Care Complaints to Reveal Hot Spots and Blind…

Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. | PSNet

psnet.ahrq.gov/issue/missed-and-delayed-diagnoses-emergency-department-study-closed-malpractice-claims-4-liability

March 02, 2011 - Study Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Citation Text: Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4…

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