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  1. Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition. | PSNet

    psnet.ahrq.gov/issue/defining-minimum-necessary-anticoagulation-related-communication-discharge-consensus-care
    March 04, 2020 - Study Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition. Citation Text: Triller D, Myrka A, Gassler J, et al. Defining Minimum Necessary Anticoagulation-Related Commu…

  2. A call to action: next steps to advance diagnosis education in the health professions. | PSNet

    psnet.ahrq.gov/issue/call-action-next-steps-advance-diagnosis-education-health-professions
    November 25, 2020 - Commentary A call to action: next steps to advance diagnosis education in the health professions. Citation Text: Graber ML, Holmboe ES, Stanley J, et al. A call to action: next steps to advance diagnosis education in the health professions. Diagnosis (Berl). 2022;9(2):166-175. doi:10.151…

  3. Do hospitals support second victims? Collective insights from patient safety leaders in Maryland. | PSNet

    psnet.ahrq.gov/issue/do-hospitals-support-second-victims-collective-insights-patient-safety-leaders-maryland
    May 11, 2016 - Study Do hospitals support second victims? Collective insights from patient safety leaders in Maryland. Citation Text: Edrees HH, Morlock L, Wu AW. Do Hospitals Support Second Victims? Collective Insights From Patient Safety Leaders in Maryland. Jt Comm J Qual Saf. 2017;43(9):471-483. do…

  4. Electronic health record-based triggers to detect adverse events after outpatient orthopaedic surgery. | PSNet

    psnet.ahrq.gov/issue/electronic-health-record-based-triggers-detect-adverse-events-after-outpatient-orthopaedic
    December 19, 2017 - Study Electronic health record-based triggers to detect adverse events after outpatient orthopaedic surgery. Citation Text: Menendez ME, Janssen SJ, Ring D. Electronic health record-based triggers to detect adverse events after outpatient orthopaedic surgery. BMJ Qual Saf. 2016;25(1):25-…

  5. An integrative review: fatigue among nurses in acute care settings. | PSNet

    psnet.ahrq.gov/issue/integrative-review-fatigue-among-nurses-acute-care-settings
    June 01, 2022 - Review An integrative review: fatigue among nurses in acute care settings. Citation Text: Smith-Miller CA, Shaw-Kokot J, Curro B, et al. An integrative review: fatigue among nurses in acute care settings. J Nurs Adm. 2014;44(9):487-94. doi:10.1097/NNA.0000000000000104. Copy Citation …

  6. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. | PSNet

    psnet.ahrq.gov/issue/urgent-need-improve-health-care-quality-institute-medicine-national-roundtable-health-care
    May 27, 2015 - Commentary Classic The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. Citation Text: Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable o…

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

    psnet.ahrq.gov/issue/cost-benefit-analysis-support-program-nursing-staff
    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…

  8. A systematic review of patient-report safety climate measures in health care. | PSNet

    psnet.ahrq.gov/issue/systematic-review-patient-report-safety-climate-measures-health-care
    September 15, 2021 - Review A systematic review of patient-report safety climate measures in health care. Citation Text: Madden C, Lydon S, O’Dowd E, et al. A systematic review of patient-report safety climate measures in health care. J Patient Saf. 2022;18(1):e51-e60. doi:10.1097/pts.0000000000000705. Cop…

  9. COVID-19: peer support and crisis communication strategies to promote institutional resilience. | PSNet

    psnet.ahrq.gov/issue/covid-19-peer-support-and-crisis-communication-strategies-promote-institutional-resilience
    February 03, 2021 - Commentary Classic COVID-19: peer support and crisis communication strategies to promote institutional resilience. Citation Text: Wu AW, Connors C, Everly GS. COVID-19: Peer Support and Crisis Communication Strategies to Promote Institutional Resilience. Ann Int…

  10. 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…

  11. In Conversation With… Enrico Coiera, MB, BS, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-enrico-coiera-mb-bs-phd
    February 01, 2014 - errors without negative unanticipated consequences.( 5 ) Certain clinical environments such as the pediatric … Examining a total of 5325 interruptions in a pediatric tertiary care setting, Hall and colleagues found … Interruptions and pediatric patient safety. J Pediatr Nurs. 2010;25:167-175. [go to PubMed] 7.

  12. High Reliability Organization (HRO) Principles and Patient Safety | PSNet

    psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
    February 26, 2025 - qualitative study found that HRO principles were unevenly implemented and understood in a Canadian pediatric … A great example of fragility is work comes from  Peter Madsen and colleagues who studied a pediatric … leader, all that went away, and the unit went right back to what they were before, an underperforming pediatric

  13. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety | PSNet

    psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
    February 26, 2025 - A great example of fragility is work comes from  Peter Madsen and colleagues who studied a pediatric … leader, all that went away, and the unit went right back to what they were before, an underperforming pediatric … qualitative study found that HRO principles were unevenly implemented and understood in a Canadian pediatric

  14. Blind Spot | PSNet

    psnet.ahrq.gov/web-mm/blind-spot
    July 30, 2020 - WebM&M Cases Intraosseous Line Extravasation in a Pediatric … View More See More About The Topic Operating Room Physicians Ophthalmology Pediatric

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865455/psn-pdf
    March 27, 2024 - One study published in 2023 found that after implementing a modified I-PASS tool, pediatric emergency … long-term-sustainability-and-adaptation-i-pass-handovers https://psnet.ahrq.gov/issue/implementation-ed-i-pass-standardized-handoff-tool-pediatric-emergency-department

  16. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. | PSNet

    psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
    March 19, 2019 - December 31, 2014 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … April 12, 2023 Evaluation and accurate diagnoses of pediatric diseases using artificial

  17. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. | PSNet

    psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
    March 15, 2023 - February 1, 2023 Association of state-level opioid-reduction policies with pediatric … August 5, 2020 Pediatric adverse drug events in the outpatient setting: an 11-year national

  18. 40 of K | PSNet

    psnet.ahrq.gov/web-mm/40-k
    January 12, 2011 - Pediatric medication order error rates related to the mode of order transmission.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49653/psn-pdf
    May 01, 2012 - Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery

  20. Deciphering the Code | PSNet

    psnet.ahrq.gov/web-mm/deciphering-code
    November 16, 2022 - More recently, a study in the pediatric literature suggested increased mortality after implementation
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