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  1. psnet.ahrq.gov/issue/effect-evidence-crisis-learning-based-perspective-integration-framework
    March 24, 2019 - Commentary The effect of evidence in crisis learning: based on a perspective integration framework. Citation Text: Wang B, Li D, Wang Y. The effect of evidence in crisis learning: based on a perspective integration framework. J Contingencies Crisis Manag. 2024;32(1):e12506. doi:10.1111/1…
  2. psnet.ahrq.gov/issue/improving-sepsis-care-through-systems-change-impact-medical-emergency-team
    December 02, 2009 - Commentary Improving sepsis care through systems change: the impact of a medical emergency team. Citation Text: Sarani B, Brenner SR, Gabel B, et al. Improving sepsis care through systems change: the impact of a medical emergency team. Jt Comm J Qual Patient Saf. 2008;34(3):179-182, 12…
  3. digital.ahrq.gov/track-5-achieving-and-sustaining-improvements
    January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…
  4. psnet.ahrq.gov/issue/henry-ford-health-system-no-harm-campaign-comprehensive-model-reduce-harm-and-save-lives
    May 11, 2019 - Commentary The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives. Citation Text: Conway WA, Hawkins S, Jordan J, et al. 2011 John M. Eisenberg Patient Safety and Quality Awards. The Henry Ford Health System No Harm Campaign: a comprehensive mo…
  5. psnet.ahrq.gov/issue/interpretability-doctor-identification-badges-uk-hospitals-survey-nurses-and-patients
    October 07, 2013 - Study The interpretability of doctor identification badges in UK hospitals: a survey of nurses and patients. Citation Text: Hickerton BC, Fitzgerald DJ, Perry E, et al. The interpretability of doctor identification badges in UK hospitals: a survey of nurses and patients. BMJ Qual Saf. 20…
  6. psnet.ahrq.gov/issue/specimen-labeling-errors-surgical-pathology-18-month-experience
    January 04, 2012 - Study Specimen labeling errors in surgical pathology: an 18-month experience. Citation Text: Layfield LJ, Anderson GM. Specimen labeling errors in surgical pathology: an 18-month experience. Am J Clin Pathol. 2010;134(3):466-70. doi:10.1309/AJCPHLQHJ0S3DFJK. Copy Citation Format:…
  7. psnet.ahrq.gov/issue/implications-case-managers-perceptions-and-attitude-safety-home-delivered-care
    September 18, 2016 - Study Implications of case managers' perceptions and attitude on safety of home-delivered care. Citation Text: Jones S. Implications of case managers' perceptions and attitude on safety of home-delivered care. Br J Community Nurs. 2015;20(12):602-7. doi:10.12968/bjcn.2015.20.12.602. Co…
  8. psnet.ahrq.gov/issue/medication-errors-resulting-computer-entry-nonprescribers
    January 02, 2017 - Study Medication errors resulting from computer entry by nonprescribers.   Citation Text: Santell JP, Kowiatek JG, Weber RJ, et al. Medication errors resulting from computer entry by nonprescribers. Am J Health Syst Pharm. 2009;66(9):843-53. doi:10.2146/ajhp080208. Copy Citation …
  9. psnet.ahrq.gov/issue/rate-occult-specimen-provenance-complications-routine-clinical-practice
    January 05, 2012 - Study Rate of occult specimen provenance complications in routine clinical practice. Citation Text: Pfeifer JD, Liu J. Rate of occult specimen provenance complications in routine clinical practice. Am J Clin Pathol. 2013;139(1):93-100. doi:10.1309/AJCP50WEZHWIFCIV. Copy Citation F…
  10. psnet.ahrq.gov/issue/serious-adverse-drug-events-reported-food-and-drug-administration-1998-2005
    June 07, 2016 - Study Serious adverse drug events reported to the Food and Drug Administration, 1998-2005. Citation Text: Moore TJ, Cohen MR, Furberg CD. Serious adverse drug events reported to the Food and Drug Administration, 1998-2005. Arch Intern Med. 2007;167(16):1752-9. Copy Citation Forma…
  11. psnet.ahrq.gov/issue/effect-electronic-checklist-critical-care-provider-workload-errors-and-performance
    January 22, 2016 - Study The effect of an electronic checklist on critical care provider workload, errors, and performance. Citation Text: Thongprayoon C, Harrison AM, O'Horo JC, et al. The Effect of an Electronic Checklist on Critical Care Provider Workload, Errors, and Performance. J Intensive Care Med. …
  12. psnet.ahrq.gov/issue/error-and-patient-safety-ethical-analysis-cases-occupational-and-physical-therapy-practice
    July 14, 2010 - Commentary Error and patient safety: ethical analysis of cases in occupational and physical therapy practice. Citation Text: Scheirton LS, Mu K, Lohman H, et al. Error and patient safety: ethical analysis of cases in occupational and physical therapy practice. Med Health Care Philos. 2…
  13. psnet.ahrq.gov/issue/spoons-systematically-bias-dosing-liquid-medicine
    November 03, 2015 - Study Spoons systematically bias dosing of liquid medicine. Citation Text: Wansink B, van Ittersum K. Spoons systematically bias dosing of liquid medicine. Ann Intern Med. 2010;152(1):66-7. doi:10.7326/0003-4819-152-1-201001050-00024. Copy Citation Format: DOI Google Scho…
  14. psnet.ahrq.gov/issue/health-outcomes-associated-potentially-inappropriate-medication-use-older-adults
    June 29, 2011 - Study Health outcomes associated with potentially inappropriate medication use in older adults. Citation Text: Fick DM, Mion LC, Beers MH, et al. Health outcomes associated with potentially inappropriate medication use in older adults. Res Nurs Health. 2008;31(1):42-51. doi:10.1002/nur…
  15. psnet.ahrq.gov/issue/effects-intervention-increase-bed-alarm-use-prevent-falls-hospitalized-patients-cluster
    January 03, 2017 - Study Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial. Citation Text: Shorr RI, Chandler M, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a clust…
  16. psnet.ahrq.gov/issue/association-overlapping-cardiac-surgery-short-term-patient-outcomes
    November 09, 2022 - Study Association of overlapping cardiac surgery with short-term patient outcomes. Citation Text: Glauser G, Goodrich S, McClintock SD, et al. Association of overlapping cardiac surgery with short-term patient outcomes. J Thorac Cardiovasc Surg. 2021;162(1):155-164.e2. doi:10.1016/j.jtc…
  17. psnet.ahrq.gov/issue/s-teams-truly-multiprofessional-course-focusing-nontechnical-skills-improve-patient-safety
    November 30, 2022 - Commentary S-TEAMS: a truly multiprofessional course focusing on nontechnical skills to improve patient safety in the operating theater. Citation Text: Stewart-Parker E, Galloway R, Vig S. S-TEAMS: A Truly Multiprofessional Course Focusing on Nontechnical Skills to Improve Patient Safety…
  18. psnet.ahrq.gov/issue/seven-hundred-and-fifty-nine-759-chances-learn-3-year-pilot-project-analyse-transfusion
    September 25, 2008 - Study Seven hundred and fifty-nine (759) chances to learn: a 3-year pilot project to analyse transfusion-related near-miss events in the Republic of Ireland. Citation Text: Lundy D, Laspina S, Kaplan H, et al. Seven hundred and fifty-nine (759) chances to learn: a 3-year pilot project …
  19. psnet.ahrq.gov/issue/occurrence-potential-patient-safety-events-among-trauma-patients-are-they-random
    July 19, 2018 - Study The occurrence of potential patient safety events among trauma patients: are they random? Citation Text: Chang DC, Handly N, Abdullah F, et al. The occurrence of potential patient safety events among trauma patients: are they random? Ann Surg. 2008;247(2):327-34. doi:10.1097/SLA.…
  20. psnet.ahrq.gov/issue/resident-duty-hour-reform-associated-increased-morbidity-following-hip-fracture
    October 19, 2022 - Study Resident duty-hour reform associated with increased morbidity following hip fracture. Citation Text: Browne JA, Cook C, Olson SA, et al. Resident duty-hour reform associated with increased morbidity following hip fracture. J Bone Joint Surg Am. 2009;91(9):2079-85. doi:10.2106/JBJ…