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  1. A review of the current evidence base for significant event analysis. | PSNet

    psnet.ahrq.gov/issue/review-current-evidence-base-significant-event-analysis
    October 14, 2009 - Review A review of the current evidence base for significant event analysis. Citation Text: Bowie P, Pope L, Lough M. A review of the current evidence base for significant event analysis. J Eval Clin Pract. 2008;14(4):520-36. doi:10.1111/j.1365-2753.2007.00908.x. Copy Citation Fo…

  2. Making use of mortality data to improve quality and safety in general practice: a review of current approaches. | PSNet

    psnet.ahrq.gov/issue/making-use-mortality-data-improve-quality-and-safety-general-practice-review-current
    November 17, 2010 - Review Making use of mortality data to improve quality and safety in general practice: a review of current approaches. Citation Text: Baker R, Sullivan E, Camosso-Stefinovic J, et al. Making use of mortality data to improve quality and safety in general practice: a review of current ap…

  3. Implementation and spread of a simple and effective way to improve the accuracy of medicines reconciliation on discharge: a hospital-based quality improvement project and success story. | PSNet

    psnet.ahrq.gov/issue/implementation-and-spread-simple-and-effective-way-improve-accuracy-medicines-reconciliation
    March 04, 2009 - Study Implementation and spread of a simple and effective way to improve the accuracy of medicines reconciliation on discharge: a hospital-based quality improvement project and success story. Citation Text: Botros S, Dunn J. Implementation and spread of a simple and effective way to impr…

  4. Who is in charge of patient safety? Work practice, work processes and utopian views of automatic drug dispensing systems. | PSNet

    psnet.ahrq.gov/issue/who-charge-patient-safety-work-practice-work-processes-and-utopian-views-automatic-drug
    September 14, 2016 - Commentary Who is in charge of patient safety? Work practice, work processes and utopian views of automatic drug dispensing systems. Citation Text: Balka E, Kahnamoui N, Nutland K. Who is in charge of patient safety? Work practice, work processes and utopian views of automatic drug dis…

  5. Educational interventions to improve handover in health care: a systematic review. | PSNet

    psnet.ahrq.gov/issue/educational-interventions-improve-handover-health-care-systematic-review
    August 04, 2021 - Review Educational interventions to improve handover in health care: a systematic review. Citation Text: Gordon M, Findley R. Educational interventions to improve handover in health care: a systematic review. Med Educ. 2011;45(11):1081-9. doi:10.1111/j.1365-2923.2011.04049.x. Copy Ci…

  6. Errors as allies: error management training in health professions education. | PSNet

    psnet.ahrq.gov/issue/errors-allies-error-management-training-health-professions-education
    January 22, 2016 - Commentary Errors as allies: error management training in health professions education. Citation Text: King A, Holder MG, Ahmed RA. Errors as allies: error management training in health professions education. BMJ Qual Saf. 2013;22(6):516-9. doi:10.1136/bmjqs-2012-000945. Copy Citatio…

  7. Safety is part of quality: a proposal for a continuum in performance measurement. | PSNet

    psnet.ahrq.gov/issue/safety-part-quality-proposal-continuum-performance-measurement
    February 25, 2009 - Study Safety is part of quality: a proposal for a continuum in performance measurement. Citation Text: Kazandjian VA, Wicker KG, Matthes N, et al. Safety is part of quality: a proposal for a continuum in performance measurement. J Eval Clin Pract. 2008;14(2):354-359. doi:10.1111/j.1365…

  8. The sensitivity of adverse event cost estimates to diagnostic coding error. | PSNet

    psnet.ahrq.gov/issue/sensitivity-adverse-event-cost-estimates-diagnostic-coding-error
    March 03, 2011 - Study The sensitivity of adverse event cost estimates to diagnostic coding error. Citation Text: Wardle G, Wodchis WP, Laporte A, et al. The sensitivity of adverse event cost estimates to diagnostic coding error. Health Serv Res. 2012;47(3 Pt 1):984-1007. doi:10.1111/j.1475-6773.2011.0…

  9. Why pediatricians fail to diagnose hypertension: a multicenter survey. | PSNet

    psnet.ahrq.gov/issue/why-pediatricians-fail-diagnose-hypertension-multicenter-survey
    August 26, 2020 - Study Why pediatricians fail to diagnose hypertension: a multicenter survey. Citation Text: Bijlsma MW, Blufpand HN, Kaspers GJL, et al. Why pediatricians fail to diagnose hypertension: a multicenter survey. J Pediatr. 2014;164(1):173-177.e7. doi:10.1016/j.jpeds.2013.08.066. Copy Cita…

  10. Measuring patient safety culture: an assessment of the clustering of responses at unit level and hospital level. | PSNet

    psnet.ahrq.gov/issue/measuring-patient-safety-culture-assessment-clustering-responses-unit-level-and-hospital
    February 20, 2013 - Study Measuring patient safety culture: an assessment of the clustering of responses at unit level and hospital level. Citation Text: Smits M, Wagner C, Spreeuwenberg P, et al. Measuring patient safety culture: an assessment of the clustering of responses at unit level and hospital lev…

  11. 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…

  12. On the CUSP: Stop BSI: evaluating the relationship between central line–associated bloodstream infection rate and patient safety climate profile. | PSNet

    psnet.ahrq.gov/issue/cusp-stop-bsi-evaluating-relationship-between-central-line-associated-bloodstream-infection
    January 30, 2013 - Study On the CUSP: Stop BSI: evaluating the relationship between central line–associated bloodstream infection rate and patient safety climate profile. Citation Text: Weaver SJ, Weeks K, Pham JC, et al. On the CUSP: Stop BSI: evaluating the relationship between central line-associated bl…

  13. Epidemiology, comparative methods of detection, and preventability of adverse drug events. | PSNet

    psnet.ahrq.gov/issue/epidemiology-comparative-methods-detection-and-preventability-adverse-drug-events
    March 09, 2016 - Study Epidemiology, comparative methods of detection, and preventability of adverse drug events. Citation Text: Al-Tajir GK, Kelly WN. Epidemiology, comparative methods of detection, and preventability of adverse drug events. Ann Pharmacother. 2005;39(7-8):1169-74. Copy Citation …

  14. Residents' perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements. | PSNet

    psnet.ahrq.gov/issue/residents-perceptions-professionalism-training-and-practice-barriers-promoters-and-duty-hour
    November 16, 2022 - Study Residents' perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements. Citation Text: Ratanawongsa N, Bolen S, Howell EE, et al. Residents' perceptions of professionalism in training and practice: barriers, promoters, and duty hour re…

  15. Creating spaces in intensive care for safe communication: a video-reflexive ethnographic study. | PSNet

    psnet.ahrq.gov/issue/creating-spaces-intensive-care-safe-communication-video-reflexive-ethnographic-study
    December 18, 2013 - Study Creating spaces in intensive care for safe communication: a video-reflexive ethnographic study. Citation Text: Hor S-Y, Iedema R, Manias E. Creating spaces in intensive care for safe communication: a video-reflexive ethnographic study. BMJ Qual Saf. 2014;23(12):1007-13. doi:10.1136…

  16. Seen through the patients' eyes: safety of chronic illness care. | PSNet

    psnet.ahrq.gov/issue/seen-through-patients-eyes-safety-chronic-illness-care
    May 16, 2018 - Study Seen through the patients' eyes: safety of chronic illness care. Citation Text: Desmedt M, Petrovic M, Bergs J, et al. Seen through the patients' eyes: Safety of chronic illness care. Int J Qual Health Care. 2017;29(7):916-921. doi:10.1093/intqhc/mzx137. Copy Citation Format:…

  17. Operating room traffic as a modifiable risk factor for surgical site infection. | PSNet

    psnet.ahrq.gov/issue/operating-room-traffic-modifiable-risk-factor-surgical-site-infection
    April 24, 2018 - Study Operating room traffic as a modifiable risk factor for surgical site infection. Citation Text: Wanta BT, Glasgow AE, Habermann EB, et al. Operating Room Traffic as a Modifiable Risk Factor for Surgical Site Infection. Surg Infect (Larchmt). 2016;17(6):755-760. Copy Citation F…

  18. The consequences of misdiagnosing race-based trauma response in Black men: a critical examination. | PSNet

    psnet.ahrq.gov/issue/consequences-misdiagnosing-race-based-trauma-response-black-men-critical-examination
    November 16, 2022 - Commentary The consequences of misdiagnosing race-based trauma response in Black men: a critical examination. Citation Text: Sanders AA, Roberts JD, McDowell MC, et al. The consequences of misdiagnosing race-based trauma response in Black men: a critical examination. Soc Work Public Heal…

  19. Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. | PSNet

    psnet.ahrq.gov/issue/stopping-error-cascade-report-ameliorators-asips-collaborative
    February 03, 2011 - Study Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. Citation Text: Parnes B, Fernald D, Quintela J, et al. Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. Qual Saf Health Care. 2007;16(1):12-6. Copy Citation …

  20. Impact of a pharmacotherapy alerting system on medication errors. | PSNet

    psnet.ahrq.gov/issue/impact-pharmacotherapy-alerting-system-medication-errors
    November 10, 2015 - Study Impact of a pharmacotherapy alerting system on medication errors. Citation Text: Natali BJ, Varkey AC, Garey KW, et al. Impact of a pharmacotherapy alerting system on medication errors. American Journal of Health-System Pharmacy. 2012;70(1). doi:10.2146/ajhp120126. Copy Citation…
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