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  1. Quality and safety in surgery: challenges and opportunities. | PSNet

    psnet.ahrq.gov/issue/quality-and-safety-surgery-challenges-and-opportunities
    September 02, 2020 - Commentary Quality and safety in surgery: challenges and opportunities. Citation Text: Nasca BJ, Bilimoria KY, Yang AD. Quality and safety in surgery: challenges and opportunities. Jt Comm J Qual Patient Saf. 2021;47(9):604-607. doi:10.1016/j.jcjq.2021.05.003. Copy Citation Format:…

  2. Oversedation of a patient with obstructive sleep apnea prior to imaging. | PSNet

    psnet.ahrq.gov/issue/oversedation-patient-obstructive-sleep-apnea-prior-imaging
    September 02, 2020 - Commentary Oversedation of a patient with obstructive sleep apnea prior to imaging. Citation Text: Blay E, Barnard C, Bilimoria KY. Oversedation of a Patient With Obstructive Sleep Apnea Prior to Imaging. JAMA. 2018;319(5):495-496. doi:10.1001/jama.2017.22004. Copy Citation Format:…

  3. Nurses' behaviors and visual scanning patterns may reduce patient identification errors. | PSNet

    psnet.ahrq.gov/issue/nurses-behaviors-and-visual-scanning-patterns-may-reduce-patient-identification-errors
    December 12, 2012 - Study Nurses' behaviors and visual scanning patterns may reduce patient identification errors. Citation Text: Marquard J, Henneman PL, He Z, et al. Nurses' behaviors and visual scanning patterns may reduce patient identification errors. J Exp Psychol Appl. 2011;17(3):247-56. doi:10.1037/…

  4. Conducting root cause analysis with nursing students: best practice in nursing education. | PSNet

    psnet.ahrq.gov/issue/conducting-root-cause-analysis-nursing-students-best-practice-nursing-education
    September 09, 2015 - Commentary Conducting root cause analysis with nursing students: best practice in nursing education. Citation Text: Lambton J, Mahlmeister L. Conducting root cause analysis with nursing students: best practice in nursing education. J Nurs Educ. 2010;49(8):444-8. doi:10.3928/01484834-…

  5. Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding ventilator-associated pneumonia? | PSNet

    psnet.ahrq.gov/issue/there-benefit-multidisciplinary-rounds-open-trauma-intensive-care-unit-regarding-ventilator
    January 06, 2010 - Study Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding ventilator-associated pneumonia? Citation Text: Johnson V, Mangram A, Mitchell C, et al. Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding v…

  6. Reframing and addressing horizontal violence as a workplace quality improvement concern. | PSNet

    psnet.ahrq.gov/issue/reframing-and-addressing-horizontal-violence-workplace-quality-improvement-concern
    March 15, 2017 - Commentary Reframing and addressing horizontal violence as a workplace quality improvement concern. Citation Text: Taylor RA, Taylor SS. Reframing and addressing horizontal violence as a workplace quality improvement concern. Nurs Forum. 2018;53(4):459-465. doi:10.1111/nuf.12273. Copy …

  7. Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans. | PSNet

    psnet.ahrq.gov/issue/improving-safety-culture-results-rhode-island-icus-lessons-learned-development-action
    September 17, 2010 - Study Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans. Citation Text: Vigorito MC, McNicoll L, Adams L, et al. Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-orie…

  8. Quick Response codes for surgical safety: a prospective pilot study. | PSNet

    psnet.ahrq.gov/issue/quick-response-codes-surgical-safety-prospective-pilot-study
    June 07, 2016 - Study Quick Response codes for surgical safety: a prospective pilot study. Citation Text: Dixon JL, Smythe WR, Momsen LS, et al. Quick Response codes for surgical safety: a prospective pilot study. Journal of Surgical Research. 2013;184(1). doi:10.1016/j.jss.2013.06.036. Copy Citatio…

  9. The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use. | PSNet

    psnet.ahrq.gov/issue/risk-adverse-drug-events-and-hospital-related-morbidity-and-mortality-among-older-adults
    October 10, 2012 - Study The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use. Citation Text: Page RL, Ruscin M. The risk of adverse drug events and hospital-related morbidity and mortality among older adults with po…

  10. Reconciliation failures lead to medication errors. | PSNet

    psnet.ahrq.gov/issue/reconciliation-failures-lead-medication-errors
    November 01, 2012 - Study Reconciliation failures lead to medication errors. Citation Text: Santell JP. Reconciliation failures lead to medication errors. Jt Comm J Qual Patient Saf. 2006;32(4):225-9. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…

  11. Impact of a pharmacist-directed pain management service on inpatient opioid use, pain control, and patient safety. | PSNet

    psnet.ahrq.gov/issue/impact-pharmacist-directed-pain-management-service-inpatient-opioid-use-pain-control-and
    February 11, 2015 - Study Impact of a pharmacist-directed pain management service on inpatient opioid use, pain control, and patient safety. Citation Text: Impact of a pharmacist-directed pain management service on inpatient opioid use, pain control, and patient safety. Poirier RH; Brown CS; Baggenstos YT; …

  12. Patient safety and collaboration of the intensive care unit team. | PSNet

    psnet.ahrq.gov/issue/patient-safety-and-collaboration-intensive-care-unit-team
    February 17, 2010 - Commentary Patient safety and collaboration of the intensive care unit team. Citation Text: Despins LA. Patient safety and collaboration of the intensive care unit team. Crit Care Nurse. 2009;29(2):85-91. doi:10.4037/ccn2009281. Copy Citation Format: DOI Google Scholar Pu…

  13. Enhancing safety reporting in adult ambulatory oncology with a clinician champion: a practice innovation. | PSNet

    psnet.ahrq.gov/issue/enhancing-safety-reporting-adult-ambulatory-oncology-clinician-champion-practice-innovation
    January 05, 2017 - Study Enhancing safety reporting in adult ambulatory oncology with a clinician champion: a practice innovation. Citation Text: Weingart SN, Price J, Duncombe D, et al. Enhancing safety reporting in adult ambulatory oncology with a clinician champion: a practice innovation. J Nurs Care …

  14. Improving teamwork on general medical units: when teams do not work face-to-face. | PSNet

    psnet.ahrq.gov/issue/improving-teamwork-general-medical-units-when-teams-do-not-work-face-face
    June 12, 2013 - Study Improving teamwork on general medical units: when teams do not work face-to-face. Citation Text: McComb SA, Henneman EA, Hinchey KT, et al. Improving teamwork on general medical units: when teams do not work face-to-face. Jt Comm J Qual Patient Saf. 2012;38(10):471-478. Copy Ci…

  15. Creating a fair and just culture: one institution's path toward organizational change. | PSNet

    psnet.ahrq.gov/issue/creating-fair-and-just-culture-one-institutions-path-toward-organizational-change
    July 23, 2014 - Commentary Creating a fair and just culture: one institution's path toward organizational change. Citation Text: Connor M, Duncombe D, Barclay E, et al. Creating a fair and just culture: one institution's pat toward organizational change. Jt Comm J Qual Patient Saf. 2007;33(10):617-24. …

  16. Does an insulin double-checking procedure improve patient safety? | PSNet

    psnet.ahrq.gov/issue/does-insulin-double-checking-procedure-improve-patient-safety
    April 24, 2018 - Study Does an insulin double-checking procedure improve patient safety? Citation Text: Modic MB, Albert NM, Sun Z, et al. Does an Insulin Double-Checking Procedure Improve Patient Safety? J Nurs Adm. 2016;46(3):154-60. doi:10.1097/NNA.0000000000000314. Copy Citation Format: …

  17. 10 years in, why time out still matters. | PSNet

    psnet.ahrq.gov/issue/10-years-why-time-out-still-matters
    November 08, 2013 - Commentary 10 years in, why time out still matters. Citation Text: Guglielmi CL, Canacari EG, DuPree ES, et al. 10 years in, why time out still matters. AORN J. 2014;99(6):783-794. doi:10.1016/j.aorn.2014.04.009. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNot…

  18. The impact of incident disclosure behaviors on medical malpractice claims. | PSNet

    psnet.ahrq.gov/issue/impact-incident-disclosure-behaviors-medical-malpractice-claims
    September 27, 2023 - Study The impact of incident disclosure behaviors on medical malpractice claims. Citation Text: Giraldo P, Sato L, Castells X. The Impact of Incident Disclosure Behaviors on Medical Malpractice Claims. J Patient Saf. 2020;16(4):e-225-e229. doi:10.1097/PTS.0000000000000342. Copy Citatio…

  19. Medication governance: preventing errors and promoting patient safety. | PSNet

    psnet.ahrq.gov/issue/medication-governance-preventing-errors-and-promoting-patient-safety
    November 08, 2023 - Commentary Medication governance: preventing errors and promoting patient safety. Citation Text: Kavanagh C. Medication governance: preventing errors and promoting patient safety. Br J Nurs. 2017;26(3):159-165. doi:10.12968/bjon.2017.26.3.159. Copy Citation Format: DOI Goog…

  20. Coaching to improve the quality of communication during briefings and debriefings. | PSNet

    psnet.ahrq.gov/issue/coaching-improve-quality-communication-during-briefings-and-debriefings
    March 02, 2022 - Study Coaching to improve the quality of communication during briefings and debriefings. Citation Text: Kleiner C, Link T, Maynard T, et al. Coaching to improve the quality of communication during briefings and debriefings. AORN J. 2014;100(4):358-68. doi:10.1016/j.aorn.2014.03.012. Co…
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