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  1. Fifteen years after To Err Is Human: a success story to learn from. | PSNet

    psnet.ahrq.gov/issue/fifteen-years-after-err-human-success-story-learn
    August 04, 2021 - Commentary Fifteen years after To Err Is Human: a success story to learn from. Citation Text: Pronovost P, Cleeman JI, Wright D, et al. Fifteen years after To Err is Human: a success story to learn from. BMJ Qual Saf. 2016;25(6):396-9. doi:10.1136/bmjqs-2015-004720. Copy Citation F…

  2. Dispensing errors and counseling quality in 100 pharmacies. | PSNet

    psnet.ahrq.gov/issue/dispensing-errors-and-counseling-quality-100-pharmacies
    December 24, 2008 - Study Dispensing errors and counseling quality in 100 pharmacies. Citation Text: Flynn EA, Barker KN, Berger BA, et al. Dispensing errors and counseling quality in 100 pharmacies. J Am Pharm Assoc (2003). 2009;49(2):171-80. doi:10.1331/JAPhA.2009.08130. Copy Citation Format: …

  3. The effect of external inspections on safety in acute hospitals in the National Health Service in England: a controlled interrupted time-series analysis. | PSNet

    psnet.ahrq.gov/issue/effect-external-inspections-safety-acute-hospitals-national-health-service-england-controlled
    January 12, 2022 - Study The effect of external inspections on safety in acute hospitals in the National Health Service in England: a controlled interrupted time-series analysis. Citation Text: Castro-Avila A, Bloor K, Thompson C. The effect of external inspections on safety in acute hospitals in the Natio…

  4. House staff team workload and organization effects on patient outcomes in an academic general internal medicine inpatient service. | PSNet

    psnet.ahrq.gov/issue/house-staff-team-workload-and-organization-effects-patient-outcomes-academic-general-internal
    February 24, 2011 - Study House staff team workload and organization effects on patient outcomes in an academic general internal medicine inpatient service. Citation Text: Ong M, Bostrom A, Vidyarthi A, et al. House staff team workload and organization effects on patient outcomes in an academic general in…

  5. Judgment errors in surgical care. | PSNet

    psnet.ahrq.gov/issue/judgment-errors-surgical-care
    December 14, 2022 - Study Judgment errors in surgical care. Citation Text: Marsh KM, Turrentine FE, Jin R, et al. Judgment errors in surgical care. J Am Coll Surg. 2024;238(5):874-879. doi:10.1097/xcs.0000000000001011. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…

  6. The use of positive deviance approach to improve health service delivery and quality of care: a scoping review. | PSNet

    psnet.ahrq.gov/issue/use-positive-deviance-approach-improve-health-service-delivery-and-quality-care-scoping
    May 29, 2024 - Review The use of positive deviance approach to improve health service delivery and quality of care: a scoping review. Citation Text: Kassie AM, Eakin E, Abate BB, et al. The use of positive deviance approach to improve health service delivery and quality of care: a scoping review. BMC H…

  7. A review of modifiable health care factors contributing to inpatient suicide: an analysis of coroners' reports using the Human Factors Analysis and Classification System for Healthcare | PSNet

    psnet.ahrq.gov/issue/review-modifiable-health-care-factors-contributing-inpatient-suicide-analysis-coroners
    July 19, 2023 - Study A review of modifiable health care factors contributing to inpatient suicide: an analysis of coroners' reports using the Human Factors Analysis and Classification System for Healthcare Citation Text: Sweeting P, Finlayson M, Hartz D. A review of modifiable health care factors contr…

  8. Medical line entanglement: the unspoken patient safety hazard of medical devices. | PSNet

    psnet.ahrq.gov/issue/medical-line-entanglement-unspoken-patient-safety-hazard-medical-devices
    May 08, 2019 - Study Medical line entanglement: the unspoken patient safety hazard of medical devices. Citation Text: Larimer C, Sumner V, Wander D. Medical line entanglement: the unspoken patient safety hazard of medical devices. Nutr Clin Pract. 2023;38(6):1296-1308. doi:10.1002/ncp.11000. Copy Cit…

  9. Design and testing of the safety agenda mobile app for managing health care managers' patient safety responsibilities. | PSNet

    psnet.ahrq.gov/issue/design-and-testing-safety-agenda-mobile-app-managing-health-care-managers-patient-safety
    July 12, 2017 - Study Design and testing of the safety agenda mobile app for managing health care managers' patient safety responsibilities. Citation Text: Mira JJ, Carrillo I, Fernandez C, et al. Design and Testing of the Safety Agenda Mobile App for Managing Health Care Managers' Patient Safety Respon…

  10. Evaluation of accuracy of IHI Trigger Tool in identifying adverse drug events: a prospective observational study. | PSNet

    psnet.ahrq.gov/issue/evaluation-accuracy-ihi-trigger-tool-identifying-adverse-drug-events-prospective
    October 18, 2023 - Study Evaluation of accuracy of IHI Trigger Tool in identifying adverse drug events: a prospective observational study. Citation Text: Silva M das DG, Martins MAP, Viana L de G, et al. Evaluation of accuracy of IHI Trigger Tool in identifying adverse drug events: a prospective observatio…

  11. A simulation systems testing program using HFMEA methodology can effectively identify and mitigate latent safety threats for a new on-site helipad. | PSNet

    psnet.ahrq.gov/issue/simulation-systems-testing-program-using-hfmea-methodology-can-effectively-identify-and
    January 03, 2017 - Study A simulation systems testing program using HFMEA methodology can effectively identify and mitigate latent safety threats for a new on-site helipad. Citation Text: Holmes J, Chipman M, Barbour T, et al. A simulation systems testing program using HFMEA methodology can effectively ide…

  12. Unveiling the hidden struggle of healthcare students as second victims through a systematic review. | PSNet

    psnet.ahrq.gov/issue/unveiling-hidden-struggle-healthcare-students-second-victims-through-systematic-review
    September 06, 2023 - Review Unveiling the hidden struggle of healthcare students as second victims through a systematic review. Citation Text: Mira JJ, Matarredona V, Tella S, et al. Unveiling the hidden struggle of healthcare students as second victims through a systematic review. BMC Med Educ. 2024;24(1):3…

  13. Association of hospital markup with preventable adverse events following pancreatic surgery in the United States. | PSNet

    psnet.ahrq.gov/issue/association-hospital-markup-preventable-adverse-events-following-pancreatic-surgery-united
    March 14, 2022 - Study Association of hospital markup with preventable adverse events following pancreatic surgery in the United States. Citation Text: Alterio RE, Abreu AA, Meier J, et al. Association of hospital markup with preventable adverse events following pancreatic surgery in the United States. C…

  14. Systematically improving physician assignment during in-hospital transitions of care by enhancing a preexisting hospital electronic health record. | PSNet

    psnet.ahrq.gov/issue/systematically-improving-physician-assignment-during-hospital-transitions-care-enhancing
    March 14, 2022 - Study Systematically improving physician assignment during in-hospital transitions of care by enhancing a preexisting hospital electronic health record. Citation Text: Zsenits B, Polashenski WA, Sterns RH, et al. Systematically improving physician assignment during in-hospital transiti…

  15. Change‐of‐shift nursing handoff interruptions: implications for evidence‐based practice. | PSNet

    psnet.ahrq.gov/issue/change-shift-nursing-handoff-interruptions-implications-evidence-based-practice
    July 19, 2023 - Study Change‐of‐shift nursing handoff interruptions: implications for evidence‐based practice. Citation Text: Rhudy LM, Johnson MR, Krecke CA, et al. Change-of-Shift Nursing Handoff Interruptions: Implications for Evidence-Based Practice. Worldviews Evid Based Nurs. 2019;16(5):362-370. d…

  16. National and local medication error reporting systems—a survey of practices in 16 countries. | PSNet

    psnet.ahrq.gov/issue/national-and-local-medication-error-reporting-systems-survey-practices-16-countries
    September 09, 2015 - Study National and local medication error reporting systems—a survey of practices in 16 countries. Citation Text: Holmström A-R, Airaksinen M, Weiss M, et al. National and local medication error reporting systems: a survey of practices in 16 countries. J Patient Saf. 2012;8(4):165-76. …

  17. Implementing electronic health record default settings to reduce opioid overprescribing: a pilot study. | PSNet

    psnet.ahrq.gov/issue/implementing-electronic-health-record-default-settings-reduce-opioid-overprescribing-pilot
    April 24, 2018 - Study Implementing electronic health record default settings to reduce opioid overprescribing: a pilot study. Citation Text: Zivin K, White JO, Chao S, et al. Implementing Electronic Health Record Default Settings to Reduce Opioid Overprescribing: A Pilot Study. Pain Med. 2019;20(1):103-…

  18. It's like sending a message in a bottle: a qualitative study of the consequences of one-way communication technologies in hospitals. | PSNet

    psnet.ahrq.gov/issue/its-sending-message-bottle-qualitative-study-consequences-one-way-communication-technologies
    December 02, 2020 - Study It's like sending a message in a bottle: a qualitative study of the consequences of one-way communication technologies in hospitals. Citation Text: Lafferty M, Harrod M, Krein SL, et al. It’s like sending a message in a bottle: a qualitative study of the consequences of one-way com…

  19. The prevalence of incivility in hospitals and the effects of incivility on patient safety culture and outcomes: a systematic review and meta-analysis. | PSNet

    psnet.ahrq.gov/issue/prevalence-incivility-hospitals-and-effects-incivility-patient-safety-culture-and-outcomes
    March 24, 2019 - Review The prevalence of incivility in hospitals and the effects of incivility on patient safety culture and outcomes: a systematic review and meta-analysis. Citation Text: Freedman B, Li WW, Liang Z, et al. The prevalence of incivility in hospitals and the effects of incivility on patie…

  20. A systematic review of clinical outcomes associated with intrahospital transitions | PSNet

    psnet.ahrq.gov/issue/systematic-review-clinical-outcomes-associated-intrahospital-transitions
    October 02, 2019 - Review A systematic review of clinical outcomes associated with intrahospital transitions Citation Text: Bristol AA, Schneider CE, Lin S-Y, et al. A Systematic Review of Clinical Outcomes Associated With Intrahospital Transitions. J Healthc Qual. 2019. doi:10.1097/JHQ.0000000000000232. …
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