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  1. Teaching students to administer medications safely. | PSNet

    psnet.ahrq.gov/issue/teaching-students-administer-medications-safely
    December 04, 2019 - Commentary Teaching students to administer medications safely. Citation Text: Koharchik L, Flavin PM. Teaching Students to Administer Medications Safely. Am J Nurs. 2017;117(1):62-66. doi:10.1097/01.NAJ.0000511573.73435.72. Copy Citation Format: DOI Google Scholar PubMed Bi…

  2. Application of the IV Medication Harm Index to assess the nature of harm averted by "smart" infusion safety systems. | PSNet

    psnet.ahrq.gov/issue/application-iv-medication-harm-index-assess-nature-harm-averted-smart-infusion-safety-systems
    January 23, 2017 - Study Application of the IV Medication Harm Index to assess the nature of harm averted by "smart" infusion safety systems. Citation Text: Williams CK, Maddox RR, Heape E, et al. Application of the IV Medication Harm Index to Assess the Nature of Harm Averted by "Smart" Infusion Safety …

  3. Measurement as a performance driver: the case for a national measurement system to improve patient safety. | PSNet

    psnet.ahrq.gov/issue/measurement-performance-driver-case-national-measurement-system-improve-patient-safety
    September 01, 2018 - Review Measurement as a performance driver: the case for a national measurement system to improve patient safety. Citation Text: Krause TR, Bell KJ, Pronovost P, et al. Measurement as a Performance Driver: The Case for a National Measurement System to Improve Patient Safety. J Patient Sa…

  4. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. | PSNet

    psnet.ahrq.gov/issue/controlled-trial-smart-infusion-pumps-improve-medication-safety-critically-ill-patients
    March 13, 2019 - Study Classic A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Citation Text: Rothschild JM, Keohane C, Cook F, et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill …

  5. Improving nurse-to-patient staffing ratios as a cost-effective safety intervention. | PSNet

    psnet.ahrq.gov/issue/improving-nurse-patient-staffing-ratios-cost-effective-safety-intervention
    May 14, 2008 - Study Improving nurse-to-patient staffing ratios as a cost-effective safety intervention. Citation Text: Rothberg MB, Abraham I, Lindenauer PK, et al. Improving nurse-to-patient staffing ratios as a cost-effective safety intervention. Med Care. 2005;43(8):785-91. Copy Citation Fo…

  6. Misunderstanding of prescription drug warning labels among patients with low literacy. | PSNet

    psnet.ahrq.gov/issue/misunderstanding-prescription-drug-warning-labels-among-patients-low-literacy
    February 28, 2011 - Study Misunderstanding of prescription drug warning labels among patients with low literacy. Citation Text: Wolf MS, Davis TC, Tilson HH, et al. Misunderstanding of prescription drug warning labels among patients with low literacy. Am J Health Syst Pharm. 2006;63(11):1048-55. Copy Ci…

  7. Learning from excellence in healthcare: a new approach to incident reporting. | PSNet

    psnet.ahrq.gov/issue/learning-excellence-healthcare-new-approach-incident-reporting
    August 31, 2022 - Commentary Learning from excellence in healthcare: a new approach to incident reporting. Citation Text: Kelly N, Blake S, Plunkett A. Learning from excellence in healthcare: a new approach to incident reporting. Arch Dis Child. 2016;101(9):788-791. doi:10.1136/archdischild-2015-310021. …

  8. Literacy and misunderstanding prescription drug labels. | PSNet

    psnet.ahrq.gov/issue/literacy-and-misunderstanding-prescription-drug-labels
    September 17, 2010 - Study Classic Literacy and misunderstanding prescription drug labels. Citation Text: Davis TC, Wolf MS, Bass PF, et al. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006;145(12):887-94. Copy Citation Format: Google Scho…

  9. IDEA4PS: the development of a research-oriented learning healthcare system. | PSNet

    psnet.ahrq.gov/issue/idea4ps-development-research-oriented-learning-healthcare-system
    April 24, 2018 - Commentary IDEA4PS: the development of a research-oriented learning healthcare system. Citation Text: Moffatt-Bruce SD, Huerta T, Gaughan A, et al. IDEA4PS: The Development of a Research-Oriented Learning Healthcare System. Am J Med Qual. 2018;33(4):420-425. doi:10.1177/1062860617751044.…

  10. Measurement is essential for improving diagnosis and reducing diagnostic error: a report from the Institute of Medicine. | PSNet

    psnet.ahrq.gov/issue/measurement-essential-improving-diagnosis-and-reducing-diagnostic-error-report-institute
    January 23, 2017 - Commentary Classic Measurement is essential for improving diagnosis and reducing diagnostic error: a report from the Institute of Medicine. Citation Text: McGlynn EA, McDonald KM, Cassel C. Measurement Is Essential for Improving Diagnosis and Reducing Diagnostic…

  11. The etiology of diagnostic errors: a controlled trial of System 1 versus System 2 reasoning. | PSNet

    psnet.ahrq.gov/issue/etiology-diagnostic-errors-controlled-trial-system-1-versus-system-2-reasoning
    July 02, 2014 - Study The etiology of diagnostic errors: a controlled trial of System 1 versus System 2 reasoning. Citation Text: Norman GR, Sherbino J, Dore KL, et al. The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning. Acad Med. 2014;89(2):277-84. doi:10.1097…

  12. The many faces of error disclosure: a common set of elements and a definition. | PSNet

    psnet.ahrq.gov/issue/many-faces-error-disclosure-common-set-elements-and-definition
    December 16, 2009 - Study Classic The many faces of error disclosure: a common set of elements and a definition. Citation Text: Fein SP, Hilborne LH, Spiritus EM, et al. The many faces of error disclosure: a common set of elements and a definition. J Gen Intern Med. 2007;22(6):75…

  13. Comparison of the clinical diagnosis and subsequent autopsy findings in medical malpractice. | PSNet

    psnet.ahrq.gov/issue/comparison-clinical-diagnosis-and-subsequent-autopsy-findings-medical-malpractice
    February 21, 2015 - Study Comparison of the clinical diagnosis and subsequent autopsy findings in medical malpractice. Citation Text: Pakis I, Polat O, Yayci N, et al. Comparison of the clinical diagnosis and subsequent autopsy findings in medical malpractice. Am J Forensic Med Pathol. 2010;31(3):218-21. …

  14. Comparison of military and civilian methods for determining potentially preventable deaths: a systematic review. | PSNet

    psnet.ahrq.gov/issue/comparison-military-and-civilian-methods-determining-potentially-preventable-deaths
    October 19, 2022 - Review Comparison of military and civilian methods for determining potentially preventable deaths: a systematic review. Citation Text: Janak JC, Sosnov JA, Bares JM, et al. Comparison of Military and Civilian Methods for Determining Potentially Preventable Deaths: A Systematic Review. JA…

  15. Characterization of prescribing errors in an internal medicine clinic. | PSNet

    psnet.ahrq.gov/issue/characterization-prescribing-errors-internal-medicine-clinic
    March 04, 2011 - Study Characterization of prescribing errors in an internal medicine clinic. Citation Text: Devine EB, Wilson-Norton JL, Lawless NM, et al. Characterization of prescribing errors in an internal medicine clinic. Am J Health Syst Pharm. 2007;64(10):1062-70. Copy Citation Format: …

  16. Economic evaluation in patient safety: a literature review of methods. | PSNet

    psnet.ahrq.gov/issue/economic-evaluation-patient-safety-literature-review-methods
    March 05, 2025 - Review Economic evaluation in patient safety: a literature review of methods. Citation Text: de Rezende BA, Or Z, Com-Ruelle L, et al. Economic evaluation in patient safety: a literature review of methods. BMJ Qual Saf. 2012;21(6):457-65. doi:10.1136/bmjqs-2011-000191. Copy Citation …

  17. Communication training, adverse events, and quality measures: 2 retrospective database analyses in Washington State hospitals. | PSNet

    psnet.ahrq.gov/issue/communication-training-adverse-events-and-quality-measures-2-retrospective-database-analyses
    August 04, 2021 - Study Communication training, adverse events, and quality measures: 2 retrospective database analyses in Washington State hospitals. Citation Text: Slade IR, Beck SJ, Kramer B, et al. Communication Training, Adverse Events, and Quality Measures: 2 Retrospective Database Analyses in Washi…

  18. Cognitive and implicit biases in nurses' judgment and decision-making: a scoping review. | PSNet

    psnet.ahrq.gov/issue/cognitive-and-implicit-biases-nurses-judgment-and-decision-making-scoping-review
    October 20, 2021 - Review Cognitive and implicit biases in nurses' judgment and decision-making: a scoping review. Citation Text: Thirsk LM, Panchuk JT, Stahlke S, et al. Cognitive and implicit biases in nurses' judgment and decision-making: a scoping review. Int J Nurs Stud. 2022;133:104284. doi:10.1016/j…

  19. Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety. | PSNet

    psnet.ahrq.gov/issue/dissecting-communication-barriers-healthcare-path-enhancing-communication-resiliency
    July 12, 2023 - Commentary Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety. Citation Text: Guttman OT, Lazzara EH, Keebler JR, et al. Dissecting Communication Barriers in Healthcare: A Path to Enhancing Communication Resilien…

  20. Provider interruptions and patient perceptions of care: an observational study in the emergency department. | PSNet

    psnet.ahrq.gov/issue/provider-interruptions-and-patient-perceptions-care-observational-study-emergency-department
    June 26, 2024 - Study Provider interruptions and patient perceptions of care: an observational study in the emergency department. Citation Text: Schneider A, Wehler M, Weigl M. Provider interruptions and patient perceptions of care: an observational study in the emergency department. BMJ Qual Saf. 2019;…
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