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  1. Use of failure mode and effects analysis to improve emergency department handoff processes. | PSNet

    psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-improve-emergency-department-handoff-processes
    October 19, 2022 - Commentary Use of failure mode and effects analysis to improve emergency department handoff processes. Citation Text: Sorrentino P. Use of Failure Mode and Effects Analysis to Improve Emergency Department Handoff Processes. Clin Nurse Spec. 2016;30(1):28-37. doi:10.1097/NUR.0000000000000…

  2. Surgical safety checklist: implementation in an ambulatory surgical facility. | PSNet

    psnet.ahrq.gov/issue/surgical-safety-checklist-implementation-ambulatory-surgical-facility
    September 23, 2020 - Study Surgical safety checklist: implementation in an ambulatory surgical facility. Citation Text: Morgan PJ, Cunningham L, Mitra S, et al. Surgical safety checklist: implementation in an ambulatory surgical facility. Can J Anaesth. 2013;60(6):528-38. doi:10.1007/s12630-013-9916-8. C…

  3. Hamilton Acute Pain Service Safety Study: using root cause analysis to reduce the incidence of adverse events. | PSNet

    psnet.ahrq.gov/issue/hamilton-acute-pain-service-safety-study-using-root-cause-analysis-reduce-incidence-adverse
    January 12, 2011 - Study Hamilton Acute Pain Service Safety Study: using root cause analysis to reduce the incidence of adverse events. Citation Text: Paul JE, Buckley N, McLean RF, et al. Hamilton acute pain service safety study: using root cause analysis to reduce the incidence of adverse events. Anesth…

  4. Physician satisfaction with transition from CPOE to paper-based prescription. | PSNet

    psnet.ahrq.gov/issue/physician-satisfaction-transition-cpoe-paper-based-prescription
    January 06, 2018 - Study Physician satisfaction with transition from CPOE to paper-based prescription. Citation Text: Griffon N, Schuers M, Joulakian M, et al. Physician satisfaction with transition from CPOE to paper-based prescription. Int J Med Inform. 2017;103:42-48. doi:10.1016/j.ijmedinf.2017.04.007.…

  5. Pharmacy prevalence of second victim syndrome in a comprehensive cancer center. | PSNet

    psnet.ahrq.gov/issue/pharmacy-prevalence-second-victim-syndrome-comprehensive-cancer-center
    June 03, 2020 - Study Pharmacy prevalence of second victim syndrome in a comprehensive cancer center. Citation Text: Johnson TN, Tucker AM. Pharmacy prevalence of second victim syndrome in a comprehensive cancer center. Am J Health-Syst Pharm. 2024;Epub Sep 13. doi:10.1093/ajhp/zxae267. Copy Citation …

  6. Retrospective analysis of medication incidents reported using an on-line reporting system. | PSNet

    psnet.ahrq.gov/issue/retrospective-analysis-medication-incidents-reported-using-line-reporting-system
    April 01, 2015 - Study Retrospective analysis of medication incidents reported using an on-line reporting system. Citation Text: Ashcroft DM, Cooke J. Retrospective analysis of medication incidents reported using an on-line reporting system. Pharmacy World & Science. 2006;28(6). doi:10.1007/s11096-006-…

  7. Comparative safety of endovascular aortic aneurysm repair over open repair using Patient Safety Indicators during adoption. | PSNet

    psnet.ahrq.gov/issue/comparative-safety-endovascular-aortic-aneurysm-repair-over-open-repair-using-patient-safety
    November 16, 2022 - Study Comparative safety of endovascular aortic aneurysm repair over open repair using Patient Safety Indicators during adoption. Citation Text: Rose J, Evans C, Barleben A, et al. Comparative safety of endovascular aortic aneurysm repair over open repair using patient safety indicators …

  8. Briefing and debriefing in the operating room using fighter pilot crew resource management. | PSNet

    psnet.ahrq.gov/issue/briefing-and-debriefing-operating-room-using-fighter-pilot-crew-resource-management
    May 29, 2024 - Study Briefing and debriefing in the operating room using fighter pilot crew resource management. Citation Text: McGreevy JM, Otten TD. Briefing and debriefing in the operating room using fighter pilot crew resource management. J Am Coll Surg. 2007;205(1):169-76. Copy Citation Fo…

  9. The impact of RVU-based compensation on patient safety outcomes in outpatient otolaryngology procedures. | PSNet

    psnet.ahrq.gov/issue/impact-rvu-based-compensation-patient-safety-outcomes-outpatient-otolaryngology-procedures
    October 19, 2022 - Study The impact of RVU-based compensation on patient safety outcomes in outpatient otolaryngology procedures. Citation Text: Stanisce L, Ahmad N, Deckard N, et al. The Impact of RVU-Based Compensation on Patient Safety Outcomes in Outpatient Otolaryngology Procedures. Otolaryngol Head N…

  10. Increasing vigilance on the medical/surgical floor to improve patient safety. | PSNet

    psnet.ahrq.gov/issue/increasing-vigilance-medicalsurgical-floor-improve-patient-safety
    January 18, 2011 - Study Increasing vigilance on the medical/surgical floor to improve patient safety. Citation Text: Jacobs JL, Apatov N, Glei M. Increasing vigilance on the medical/surgical floor to improve patient safety. J Adv Nurs. 2007;57(5). doi:10.1111/j.1365-2648.2006.04161.x. Copy Citation …

  11. Hospital admissions due to adverse drug reactions: a report from the Boston Collaborative Drug Surveillance Program. | PSNet

    psnet.ahrq.gov/issue/hospital-admissions-due-adverse-drug-reactions-report-boston-collaborative-drug-surveillance
    March 01, 2023 - Study Classic Hospital admissions due to adverse drug reactions: a report from the Boston Collaborative Drug Surveillance Program. Citation Text: Miller RR. Hospital admissions due to adverse drug reactions. A report from the Boston Collaborative Drug Surveill…

  12. Agreement of expert judgment in causality assessment of adverse drug reactions. | PSNet

    psnet.ahrq.gov/issue/agreement-expert-judgment-causality-assessment-adverse-drug-reactions
    November 29, 2023 - Study Agreement of expert judgment in causality assessment of adverse drug reactions. Citation Text: Arimone Y, Bégaud B, Miremont-Salamé G, et al. Agreement of expert judgment in causality assessment of adverse drug reactions. Eur J Clin Pharmacol. 2005;61(3):169-73. Copy Citation …

  13. Time out: the impact of physician burnout on patient care quality and safety in perioperative medicine. | PSNet

    psnet.ahrq.gov/issue/time-out-impact-physician-burnout-patient-care-quality-and-safety-perioperative-medicine
    November 03, 2021 - Commentary Time out: the impact of physician burnout on patient care quality and safety in perioperative medicine. Citation Text: Shin P, Desai V, Conte AH, et al. Time out: the impact of physician burnout on patient care quality and safety in perioperative medicine. Perm J. 2023;27(2):1…

  14. Incidence and prevention of iatrogenic urethral injuries. | PSNet

    psnet.ahrq.gov/issue/incidence-and-prevention-iatrogenic-urethral-injuries
    August 02, 2015 - Study Incidence and prevention of iatrogenic urethral injuries. Citation Text: Kashefi C, Messer K, Barden R, et al. Incidence and prevention of iatrogenic urethral injuries. J Urol. 2008;179(6):2254-7; discussion 2257-8. doi:10.1016/j.juro.2008.01.108. Copy Citation Format: …

  15. A socio-technical systems approach to studying interruptions: understanding the interrupter's perspective. | PSNet

    psnet.ahrq.gov/issue/socio-technical-systems-approach-studying-interruptions-understanding-interrupters
    October 03, 2013 - Study A socio-technical systems approach to studying interruptions: understanding the interrupter's perspective. Citation Text: Rivera J. A socio-technical systems approach to studying interruptions: understanding the interrupter's perspective. Appl Ergon. 2014;45(3):747-56. doi:10.1016/…

  16. Patient identification error among prostate needle core biopsy specimens—are we ready for a DNA time-out? | PSNet

    psnet.ahrq.gov/issue/patient-identification-error-among-prostate-needle-core-biopsy-specimens-are-we-ready-dna
    March 12, 2025 - Study Patient identification error among prostate needle core biopsy specimens—are we ready for a DNA time-out? Citation Text: Suba EJ, Pfeifer JD, Raab SS. Patient identification error among prostate needle core biopsy specimens--are we ready for a DNA time-out? J Urol. 2007;178(4 Pt …

  17. The 2011 duty-hour requirements—a survey of residency program directors. | PSNet

    psnet.ahrq.gov/issue/2011-duty-hour-requirements-survey-residency-program-directors
    December 02, 2014 - Study The 2011 duty-hour requirements—a survey of residency program directors. Citation Text: Drolet BC, Khokhar MT, Fischer SA. The 2011 duty-hour requirements--a survey of residency program directors. N Engl J Med. 2013;368(8):694-7. doi:10.1056/NEJMp1214483. Copy Citation Form…

  18. Duty-hours monitoring revisited: self-report may not be adequate. | PSNet

    psnet.ahrq.gov/issue/duty-hours-monitoring-revisited-self-report-may-not-be-adequate
    April 24, 2018 - Study Duty-hours monitoring revisited: self-report may not be adequate. Citation Text: Buum HAT, Duran-Nelson AM, Menk J, et al. Duty-hours monitoring revisited: self-report may not be adequate. Am J Med. 2013;126(4):362-5. doi:10.1016/j.amjmed.2012.12.003. Copy Citation Format: …

  19. Analgesic-related medication errors reported to US Poison Control Centers. | PSNet

    psnet.ahrq.gov/issue/analgesic-related-medication-errors-reported-us-poison-control-centers
    June 06, 2018 - Study Analgesic-related medication errors reported to US Poison Control Centers. Citation Text: Eluri M, Spiller HA, Casavant MJ, et al. Analgesic-Related Medication Errors Reported to US Poison Control Centers. Pain Med. 2018;19(12):2357-2370. doi:10.1093/pm/pnx272. Copy Citation …

  20. Informatics opportunities: the intersection of patient safety and clinical informatics. | PSNet

    psnet.ahrq.gov/issue/informatics-opportunities-intersection-patient-safety-and-clinical-informatics
    May 27, 2011 - Commentary Informatics opportunities: the intersection of patient safety and clinical informatics. Citation Text: Kilbridge PM, Classen D. The informatics opportunities at the intersection of patient safety and clinical informatics. J Am Med Inform Assoc. 2008;15(4):397-407. doi:10.119…
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