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  1. Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go. | PSNet

    psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems-months-shutdown-then
    July 18, 2018 - Newspaper/Magazine Article Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go. Citation Text: Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go. Massey W, Keith …

  2. Teach-Back Tips (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/teach-back-tips-jobaid-final508.pdf
    June 02, 2025 - Teach-Back Tips Teach-Back Tips All patients can benefit from teach-back. � Ask patients to teach information back to you in their own words, not just repeat your words. � Use plain language (blood thinner for anticoagulant, heart doctor for cardiologist). � Rephrase your message until the patient understa…

  3. Track 6: Using Reporting Systems for Safety and Quality Improvement | Digital Healthcare Research

    digital.ahrq.gov/track-6-using-reporting-systems-safety-and-quality-improvement
    January 01, 2023 - Persons with disabilities having difficulty accessing this information should contact us at: https:/

  4. Surgical simulation: a systematic review. | PSNet

    psnet.ahrq.gov/issue/surgical-simulation-systematic-review
    June 15, 2011 - Review Surgical simulation: a systematic review. Citation Text: Sutherland LM, Middleton PF, Anthony A, et al. Surgical simulation: a systematic review. Ann Surg. 2006;243(3):291-300. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …

  5. How to avoid paediatric medication errors: a user's guide to the literature. | PSNet

    psnet.ahrq.gov/issue/how-avoid-paediatric-medication-errors-users-guide-literature
    May 26, 2011 - Review How to avoid paediatric medication errors: a user's guide to the literature. Citation Text: Walsh KE, Kaushal R, Chessare JB. How to avoid paediatric medication errors: a user's guide to the literature. Arch Dis Child. 2005;90(7):698-702. Copy Citation Format: Goog…

  6. Misinformation in the medical literature: what role do error and fraud play? | PSNet

    psnet.ahrq.gov/issue/misinformation-medical-literature-what-role-do-error-and-fraud-play
    November 02, 2011 - Commentary Misinformation in the medical literature: what role do error and fraud play? Citation Text: Steen G. Misinformation in the medical literature: what role do error and fraud play? J Med Ethics. 2011;37(8):498-503. doi:10.1136/jme.2010.041830. Copy Citation Format: …

  7. Special Section: IEA Health Care 2021. | PSNet

    psnet.ahrq.gov/issue/special-section-iea-health-care-2021
    August 02, 2010 - Special or Theme Issue Special Section: IEA Health Care 2021. Citation Text: Special Section: IEA Health Care 2021. Hum Factors. 2024;66(3):633-769. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter …

  8. Using information to optimize medical outcomes. | PSNet

    psnet.ahrq.gov/issue/using-information-optimize-medical-outcomes
    August 04, 2021 - Commentary Using information to optimize medical outcomes. Citation Text: Duncan JR. Using Information to Optimize Medical Outcomes. JAMA. 2009;301(22). doi:10.1001/jama.2009.827. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …

  9. Measuring team performance in healthcare: review of research and implications for patient safety. | PSNet

    psnet.ahrq.gov/issue/measuring-team-performance-healthcare-review-research-and-implications-patient-safety
    November 20, 2019 - Review Measuring team performance in healthcare: review of research and implications for patient safety. Citation Text: Jeffcott SA, Mackenzie CF. Measuring team performance in healthcare: review of research and implications for patient safety. J Crit Care. 2008;23(2):188-96. doi:10.10…

  10. Clinical drug interactions in outpatients of a university hospital in Thailand. | PSNet

    psnet.ahrq.gov/issue/clinical-drug-interactions-outpatients-university-hospital-thailand
    September 20, 2011 - Study Clinical drug interactions in outpatients of a university hospital in Thailand. Citation Text: Janchawee B, Owatranporn T, Mahatthanatrakul W, et al. Clinical drug interactions in outpatients of a university hospital in Thailand. J Clin Pharm Ther. 2005;30(6):583-90. Copy Citat…

  11. Like night and day — shedding light on off-hours care. | PSNet

    psnet.ahrq.gov/issue/night-and-day-shedding-light-hours-care
    September 28, 2010 - Commentary Like night and day — shedding light on off-hours care. Citation Text: Shulkin DJ. Like night and day--shedding light on off-hours care. N Engl J Med. 2008;358(20):2091-3. doi:10.1056/NEJMp0707144. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X…

  12. Health literacy and communication quality in health care organizations. | PSNet

    psnet.ahrq.gov/issue/health-literacy-and-communication-quality-health-care-organizations
    November 26, 2014 - Study Health literacy and communication quality in health care organizations. Citation Text: Wynia M, Osborn CY. Health literacy and communication quality in health care organizations. J Health Commun. 2010;15 Suppl 2:102-15. doi:10.1080/10810730.2010.499981. Copy Citation Format…

  13. Quality and safety in surgical care. | PSNet

    psnet.ahrq.gov/issue/quality-and-safety-surgical-care
    August 26, 2011 - Commentary Quality and safety in surgical care. Citation Text: Polk HC, Birkmeyer JD, Hunt D, et al. Quality and safety in surgical care. Ann Surg. 2006;243(4):439-48. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

  14. Risk of mistaken DNR orders. | PSNet

    psnet.ahrq.gov/issue/risk-mistaken-dnr-orders
    October 19, 2022 - Study Risk of mistaken DNR orders. Citation Text: Rohrer JE, Esler WV, Saeed Q, et al. Risk of mistaken DNR orders. Supportive Care in Cancer. 2006;14(8). doi:10.1007/s00520-006-0023-z. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

  15. Long-term solution to malpractice crises: reduce harm to patients. | PSNet

    psnet.ahrq.gov/issue/long-term-solution-malpractice-crises-reduce-harm-patients
    September 12, 2018 - Commentary Long-term solution to malpractice crises: reduce harm to patients. Citation Text: Schoenbaum S, Segel K. Long-term solution to malpractice crises: reduce harm to patients. Physician Exec. 2006;32(2):26-9, 31. Copy Citation Format: Google Scholar PubMed BibTeX E…

  16. Fallacious reasoning and complexity as root causes of clinical inertia. | PSNet

    psnet.ahrq.gov/issue/fallacious-reasoning-and-complexity-root-causes-clinical-inertia
    June 17, 2020 - Commentary Fallacious reasoning and complexity as root causes of clinical inertia. Citation Text: Miles RW. Fallacious reasoning and complexity as root causes of clinical inertia. J Am Med Dir Assoc. 2007;8(6):349-54. Copy Citation Format: Google Scholar PubMed BibTeX End…

  17. Using standardised patients in an objective structured clinical examination as a patient safety tool. | PSNet

    psnet.ahrq.gov/issue/using-standardised-patients-objective-structured-clinical-examination-patient-safety-tool
    April 21, 2010 - Commentary Using standardised patients in an objective structured clinical examination as a patient safety tool. Citation Text: Battles JB, Wilkinson SL, Lee SJ. Using standardised patients in an objective structured clinical examination as a patient safety tool. Qual Saf Health Care. …

  18. Older Adults and COVID-19: Implications for Aging Policy and Practice. | PSNet

    psnet.ahrq.gov/issue/older-adults-and-covid-19-implications-aging-policy-and-practice
    July 18, 2018 - Special or Theme Issue Older Adults and COVID-19: Implications for Aging Policy and Practice. Citation Text: Older Adults and COVID-19: Implications for Aging Policy and Practice. Miller EA, ed. J Aging Soc Policy. 2020;32(4-5):297-535. Copy Citation Save …

  19. COVID-19 Focused Inspection Initiative in Healthcare. | PSNet

    psnet.ahrq.gov/issue/covid-19-focused-inspection-initiative-healthcare
    April 01, 2024 - Press Release/Announcement COVID-19 Focused Inspection Initiative in Healthcare. Citation Text: COVID-19 Focused Inspection Initiative in Healthcare. Occupational Safety and Health Administration. March 2, 2022. Copy Citation Save Save to your library …

  20. Procedural safety in emergency care: a conceptual model and recommendations. | PSNet

    psnet.ahrq.gov/issue/procedural-safety-emergency-care-conceptual-model-and-recommendations
    July 02, 2011 - Commentary Procedural safety in emergency care: a conceptual model and recommendations. Citation Text: Pines JM, Kelly JJ, Meisl H, et al. Procedural safety in emergency care: a conceptual model and recommendations. Jt Comm J Qual Patient Saf. 2012;38(11):516-526. Copy Citation F…
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