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  1. Has the pendulum swung too far?; The impact of missed abdominal injuries in the era of nonoperative management. | PSNet

    psnet.ahrq.gov/issue/has-pendulum-swung-too-far-impact-missed-abdominal-injuries-era-nonoperative-management
    August 04, 2021 - Study Has the pendulum swung too far?; The impact of missed abdominal injuries in the era of nonoperative management. Citation Text: Fairfax LM, Christmas B, Deaugustinis M, et al. Has the pendulum swung too far? The impact of missed abdominal injuries in the era of nonoperative manage…

  2. Detection of potential look-alike/sound-alike medication errors using Veterans Affairs administrative databases. | PSNet

    psnet.ahrq.gov/issue/detection-potential-look-alikesound-alike-medication-errors-using-veterans-affairs
    October 04, 2011 - Study Detection of potential look-alike/sound-alike medication errors using Veterans Affairs administrative databases. Citation Text: Zacher JM, Cunningham FE, Zhao X, et al. Detection of potential look-alike/sound-alike medication errors using Veterans Affairs administrative databases. …

  3. Inadequate preoperative team briefings lead to more intraoperative adverse events. | PSNet

    psnet.ahrq.gov/issue/inadequate-preoperative-team-briefings-lead-more-intraoperative-adverse-events
    June 07, 2023 - Study Inadequate preoperative team briefings lead to more intraoperative adverse events. Citation Text: Phadnis J, Templeton-Ward O. Inadequate Preoperative Team Briefings Lead to More Intraoperative Adverse Events. J Patient Saf. 2018;14(2):82-86. doi:10.1097/PTS.0000000000000181. Cop…

  4. Hospital progress in reducing error: the impact of external interventions. | PSNet

    psnet.ahrq.gov/issue/hospital-progress-reducing-error-impact-external-interventions
    December 04, 2016 - Study Hospital progress in reducing error: the impact of external interventions. Citation Text: Hosford SB. Hospital progress in reducing error: the impact of external interventions. Hosp Top. 2008;86(1):9-19. doi:10.3200/HTPS.86.1.9-20. Copy Citation Format: DOI Google S…

  5. Systematic assessment of culture review as a tool to assess errors in the clinical microbiology laboratory. | PSNet

    psnet.ahrq.gov/issue/systematic-assessment-culture-review-tool-assess-errors-clinical-microbiology-laboratory
    November 16, 2022 - Study Systematic assessment of culture review as a tool to assess errors in the clinical microbiology laboratory. Citation Text: Goodyear N, Ulness BK, Prentice JL, et al. Systematic assessment of culture review as a tool to assess errors in the clinical microbiology laboratory. Arch P…

  6. When a vital sign leads a country astray—the opioid epidemic. | PSNet

    psnet.ahrq.gov/issue/when-vital-sign-leads-country-astray-opioid-epidemic
    May 27, 2020 - Commentary When a vital sign leads a country astray—the opioid epidemic. Citation Text: Chidgey BA, McGinigle KL, McNaull PP. When a Vital Sign Leads a Country Astray—The Opioid Epidemic. JAMA Surg. 2019;154(11):987-988. doi:10.1001/jamasurg.2019.2104. Copy Citation Format: …

  7. What near misses tell us about risk and safety in mental health care. | PSNet

    psnet.ahrq.gov/issue/what-near-misses-tell-us-about-risk-and-safety-mental-health-care
    October 19, 2022 - Study What near misses tell us about risk and safety in mental health care. Citation Text: Jeffs L, Rose D, Macrae C, et al. What near misses tell us about risk and safety in mental health care. J Psychiatr Ment Health Nurs. 2012;19(5):430-7. doi:10.1111/j.1365-2850.2011.01812.x. Cop…

  8. The error of omission: a simple checklist approach for improving operating room safety. | PSNet

    psnet.ahrq.gov/issue/error-omission-simple-checklist-approach-improving-operating-room-safety
    August 03, 2022 - Commentary The error of omission: a simple checklist approach for improving operating room safety. Citation Text: Rosenfield LK, Chang DS. The error of omission: a simple checklist approach for improving operating room safety. Plast Reconstr Surg. 2009;123(1):399-402. doi:10.1097/PRS.0…

  9. Resident physicians' advice seeking and error making: a social networks approach. | PSNet

    psnet.ahrq.gov/issue/resident-physicians-advice-seeking-and-error-making-social-networks-approach
    July 13, 2010 - Study Resident physicians' advice seeking and error making: a social networks approach. Citation Text: Katz-Navon T, Naveh E. Resident physicians' advice seeking and error making: a social networks approach. Health Care Manage Rev. 2022;47(3):e41-e49. doi:10.1097/hmr.0000000000000333. …

  10. Infection prevention in long-term care: re-evaluating the system using a human factors engineering approach. | PSNet

    psnet.ahrq.gov/issue/infection-prevention-long-term-care-re-evaluating-system-using-human-factors-engineering
    August 21, 2024 - Commentary Infection prevention in long-term care: re-evaluating the system using a human factors engineering approach. Citation Text: Katz MJ, Gurses AP. Infection prevention in long-term care: re-evaluating the system using a human factors engineering approach. Infect Control Hosp Epid…

  11. Novel approach to cardiac alarm management on telemetry units. | PSNet

    psnet.ahrq.gov/issue/novel-approach-cardiac-alarm-management-telemetry-units
    October 27, 2021 - Study Novel approach to cardiac alarm management on telemetry units. Citation Text: Whalen DA, Covelle PM, Piepenbrink JC, et al. Novel approach to cardiac alarm management on telemetry units. J Cardiovasc Nurs. 2014;29(5):E13-22. doi:10.1097/JCN.0000000000000114. Copy Citation For…

  12. A model of disruptive surgeon behavior in the perioperative environment. | PSNet

    psnet.ahrq.gov/issue/model-disruptive-surgeon-behavior-perioperative-environment
    February 05, 2020 - Study A model of disruptive surgeon behavior in the perioperative environment. Citation Text: Cochran A, Elder WB. A model of disruptive surgeon behavior in the perioperative environment. J Am Coll Surg. 2014;219(3):390-8. doi:10.1016/j.jamcollsurg.2014.05.011. Copy Citation Format…

  13. Surgeon fatigue: a prospective analysis of the incidence, risk, and intervals of predicted fatigue-related impairment in residents. | PSNet

    psnet.ahrq.gov/issue/surgeon-fatigue-prospective-analysis-incidence-risk-and-intervals-predicted-fatigue-related
    July 06, 2011 - Study Surgeon fatigue: a prospective analysis of the incidence, risk, and intervals of predicted fatigue-related impairment in residents. Citation Text: McCormick F, Kadzielski J, Landrigan CP, et al. Surgeon fatigue: a prospective analysis of the incidence, risk, and intervals of predic…

  14. Medication reconciliation to facilitate transitions of care after hospitalization. | PSNet

    psnet.ahrq.gov/issue/medication-reconciliation-facilitate-transitions-care-after-hospitalization
    December 02, 2015 - Commentary Medication reconciliation to facilitate transitions of care after hospitalization. Citation Text: Liu VC, Garwood CL. Medication reconciliation to facilitate transitions of care after hospitalization. Am J Health Syst Pharm. 2015;72(9):690-693. doi:10.2146/ajhp140133. Copy C…

  15. Impact of senior clinical review on patient disposition from the emergency department. | PSNet

    psnet.ahrq.gov/issue/impact-senior-clinical-review-patient-disposition-emergency-department
    August 28, 2024 - Study Impact of senior clinical review on patient disposition from the emergency department. Citation Text: White AL, Armstrong PAR, Thakore S. Impact of senior clinical review on patient disposition from the emergency department. Emerg Med J. 2010;27(4):262-5, 296. doi:10.1136/emj.200…

  16. The evolution of patient safety procedures in an oral surgery department | PSNet

    psnet.ahrq.gov/issue/evolution-patient-safety-procedures-oral-surgery-department
    November 16, 2022 - Commentary The evolution of patient safety procedures in an oral surgery department Citation Text: Graham C, Reid S, Lord TC, et al. The evolution of patient safety procedures in an oral surgery department. Br Dent J. 2019;226(1):32-38. doi:10.1038/sj.bdj.2019.5. Copy Citation Form…

  17. Examining the effects of an obstetrics interprofessional programme on reductions to reportable events and their related costs. | PSNet

    psnet.ahrq.gov/issue/examining-effects-obstetrics-interprofessional-programme-reductions-reportable-events-and
    August 04, 2021 - Study Examining the effects of an obstetrics interprofessional programme on reductions to reportable events and their related costs. Citation Text: Geary M, Ruiter PJA, Yasseen AS. Examining the effects of an obstetrics interprofessional programme on reductions to reportable events and t…

  18. A realist synthesis of interprofessional patient safety activities and healthcare student attitudes towards patient safety. | PSNet

    psnet.ahrq.gov/issue/realist-synthesis-interprofessional-patient-safety-activities-and-healthcare-student
    July 01, 2019 - Review A realist synthesis of interprofessional patient safety activities and healthcare student attitudes towards patient safety. Citation Text: Cleary E, Bloomfield J, Frotjold A, et al. A realist synthesis of interprofessional patient safety activities and healthcare student attitudes…

  19. Comparison of barcode scanning by pharmacy technicians and pharmacists' visual checks for final product verification. | PSNet

    psnet.ahrq.gov/issue/comparison-barcode-scanning-pharmacy-technicians-and-pharmacists-visual-checks-final-product
    August 31, 2016 - Study Comparison of barcode scanning by pharmacy technicians and pharmacists' visual checks for final product verification. Citation Text: Wang BN-T, Brummond P, Stevenson JG. Comparison of barcode scanning by pharmacy technicians and pharmacists' visual checks for final product verifica…

  20. Using learning communities to support adoption of health care innovations. | PSNet

    psnet.ahrq.gov/issue/using-learning-communities-support-adoption-health-care-innovations
    March 15, 2017 - Commentary Using learning communities to support adoption of health care innovations. Citation Text: Carpenter D, Hassell S, Mardon R, et al. Using Learning Communities to Support Adoption of Health Care Innovations. Jt Comm J Qual Patient Saf. 2018;44(10):566-573. doi:10.1016/j.jcjq.201…
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