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  1. Learning from incidents in healthcare: the journey, not the arrival, matters. | PSNet

    psnet.ahrq.gov/issue/learning-incidents-healthcare-journey-not-arrival-matters
    June 12, 2024 - Commentary Learning from incidents in healthcare: the journey, not the arrival, matters. Citation Text: Leistikow I, Mulder S, Vesseur J, et al. Learning from incidents in healthcare: the journey, not the arrival, matters. BMJ Qual Saf. 2017;26(3):252-256. doi:10.1136/bmjqs-2015-004853. …

  2. Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II. | PSNet

    psnet.ahrq.gov/issue/selected-medical-errors-intensive-care-unit-results-iatroref-study-parts-i-and-ii
    April 18, 2012 - Study Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II. Citation Text: Garrouste-Orgeas M, Timsit JF, Vesin A, et al. Selected Medical Errors in the Intensive Care Unit. Am J Respir Crit Care Med. 2009;181(2):134-142. doi:10.1164/rccm.20…

  3. Impact of organizational culture on preventability assessment of selected adverse events in the ICU: evaluation of morbidity and mortality conferences. | PSNet

    psnet.ahrq.gov/issue/impact-organizational-culture-preventability-assessment-selected-adverse-events-icu
    August 15, 2016 - Study Impact of organizational culture on preventability assessment of selected adverse events in the ICU: evaluation of morbidity and mortality conferences. Citation Text: Pelieu I, Djadi-Prat J, Consoli SM, et al. Impact of organizational culture on preventability assessment of selec…

  4. Operating room organization and surgical performance: a systematic review. | PSNet

    psnet.ahrq.gov/issue/operating-room-organization-and-surgical-performance-systematic-review
    March 05, 2025 - Review Operating room organization and surgical performance: a systematic review. Citation Text: Pasquer A, Ducarroz S, Lifante JC, et al. Operating room organization and surgical performance: a systematic review. Patient Saf Surg. 2024;18(1):5. doi:10.1186/s13037-023-00388-3. Copy Cit…

  5. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. | PSNet

    psnet.ahrq.gov/issue/diagnostic-blood-loss-phlebotomy-and-hospital-acquired-anemia-during-acute-myocardial
    March 14, 2022 - Study Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Citation Text: Salisbury AC, Reid KJ, Alexander KP, et al. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med…

  6. Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review. | PSNet

    psnet.ahrq.gov/issue/problems-health-information-technology-and-their-effects-care-delivery-and-patient-outcomes
    February 14, 2024 - Review Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review. Citation Text: Kim MO, Coiera E, Magrabi F. Problems with health information technology and their effects on care delivery and patient outcomes: a systematic r…

  7. SAFER Care: improving caregiver comprehension of discharge instructions. | PSNet

    psnet.ahrq.gov/issue/safer-care-improving-caregiver-comprehension-discharge-instructions
    October 26, 2022 - Study SAFER Care: improving caregiver comprehension of discharge instructions. Citation Text: Uong A, Philips K, Hametz P, et al. SAFER care: improving caregiver comprehension of discharge instructions. Pediatrics. 2021;147(4):e20200031. doi:10.1542/peds.2020-0031. Copy Citation Fo…

  8. Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients. | PSNet

    psnet.ahrq.gov/issue/assessment-safety-enhancement-hospital-medication-reconciliation-process-elderly-patients
    August 04, 2021 - Study Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients. Citation Text: Gizzi LA, Slain D, Hare JT, et al. Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients. Am J Geriatr Phar…

  9. Pharmacist- versus physician-acquired medication history: a prospective study at the emergency department. | PSNet

    psnet.ahrq.gov/issue/pharmacist-versus-physician-acquired-medication-history-prospective-study-emergency
    June 17, 2014 - Study Pharmacist- versus physician-acquired medication history: a prospective study at the emergency department. Citation Text: De Winter S, Spriet I, Indevuyst C, et al. Pharmacist- versus physician-acquired medication history: a prospective study at the emergency department. Qual Saf…

  10. The effect on medication errors of pharmacists charting medication in an emergency department. | PSNet

    psnet.ahrq.gov/issue/effect-medication-errors-pharmacists-charting-medication-emergency-department
    November 16, 2022 - Study The effect on medication errors of pharmacists charting medication in an emergency department. Citation Text: Vasileff HM, Whitten LE, Pink JA, et al. The effect on medication errors of pharmacists charting medication in an emergency department. Pharm World Sci. 2009;31(3):373-9.…

  11. Exploring the impact of employee engagement and patient safety. | PSNet

    psnet.ahrq.gov/issue/exploring-impact-employee-engagement-and-patient-safety
    July 27, 2022 - Review Exploring the impact of employee engagement and patient safety. Citation Text: Scott G, Hogden A, Taylor R, et al. Exploring the impact of employee engagement and patient safety. Int J Qual Health Care. 2022;34(3):mzac059. doi:10.1093/intqhc/mzac059. Copy Citation Format: …

  12. Mindful workarounds in bar code medication administration. | PSNet

    psnet.ahrq.gov/issue/mindful-workarounds-bar-code-medication-administration
    July 20, 2022 - Commentary Mindful workarounds in bar code medication administration. Citation Text: Lichtner V, Dowding D. Mindful workarounds in bar code medication administration. Stud Health Technol Inform. 2022;294:740-744. doi:10.3233/shti220575. Copy Citation Format: DOI Google Scho…

  13. Characteristics and predictors of missed opportunities in lung cancer diagnosis: an electronic health record-based study. | PSNet

    psnet.ahrq.gov/issue/characteristics-and-predictors-missed-opportunities-lung-cancer-diagnosis-electronic-health
    January 19, 2012 - Study Characteristics and predictors of missed opportunities in lung cancer diagnosis: an electronic health record-based study. Citation Text: Singh H, Hirani K, Kadiyala H, et al. Characteristics and predictors of missed opportunities in lung cancer diagnosis: an electronic health rec…

  14. The effect of clinician feedback interventions on opioid prescribing. | PSNet

    psnet.ahrq.gov/issue/effect-clinician-feedback-interventions-opioid-prescribing
    November 17, 2021 - Study The effect of clinician feedback interventions on opioid prescribing. Citation Text: Navathe AS, Liao JM, Yan XS, et al. The effect of clinician feedback interventions on opioid prescribing. Health Aff (Millwood). 2022;41(3):424-433. doi:10.1377/hlthaff.2021.01407. Copy Citation …

  15. An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study. | PSNet

    psnet.ahrq.gov/issue/intervention-improve-transitions-nicu-ambulatory-care-quasi-experimental-study
    December 30, 2014 - Study An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study. Citation Text: Moyer VA, Papile L-A, Eichenwald E, et al. An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study. BMJ Qual Saf. 2014;23(12):e3. …

  16. Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: an Utstein-style scientific statement. | PSNet

    psnet.ahrq.gov/issue/recommended-guidelines-monitoring-reporting-and-conducting-research-medical-emergency-team
    August 04, 2021 - Commentary Recommended guidelines for monitoring, reporting, and conducting research on medical emergency team, outreach, and rapid response systems: an Utstein-style scientific statement. Citation Text: Peberdy MA, Cretikos MA, Abella BS, et al. Recommended Guidelines for Monitoring, …

  17. Defining the incidence of cardiorespiratory instability in patients in step-down units using an electronic integrated monitoring system. | PSNet

    psnet.ahrq.gov/issue/defining-incidence-cardiorespiratory-instability-patients-step-down-units-using-electronic
    September 04, 2013 - Study Defining the incidence of cardiorespiratory instability in patients in step-down units using an electronic integrated monitoring system. Citation Text: Hravnak M, Edwards L, Clontz A, et al. Defining the incidence of cardiorespiratory instability in patients in step-down units us…

  18. Artificial intelligence, bias and clinical safety. | PSNet

    psnet.ahrq.gov/issue/artificial-intelligence-bias-and-clinical-safety
    September 23, 2020 - Review Artificial intelligence, bias and clinical safety. Citation Text: Challen R, Denny J, Pitt M, et al. Artificial intelligence, bias and clinical safety. BMJ Qual Saf. 2019;28(3):231-237. doi:10.1136/bmjqs-2018-008370. Copy Citation Format: DOI Google Scholar PubMed Bi…

  19. Nurses' perceived causes of medication administration errors: a qualitative systematic review. | PSNet

    psnet.ahrq.gov/issue/nurses-perceived-causes-medication-administration-errors-qualitative-systematic-review
    September 16, 2020 - Review Nurses' perceived causes of medication administration errors: a qualitative systematic review. Citation Text: Schroers G, Ross JG, Moriarty H. Nurses' perceived causes of medication administration errors: a qualitative systematic review. Jt Comm J Qual Patient Saf. 2021;47(1):38-5…

  20. Using near-miss events to improve MRI safety in a large academic centre. | PSNet

    psnet.ahrq.gov/issue/using-near-miss-events-improve-mri-safety-large-academic-centre
    May 31, 2017 - Commentary Using near-miss events to improve MRI safety in a large academic centre. Citation Text: Goolsarran N, Martinez J, Garcia C. Using near-miss events to improve MRI safety in a large academic centre. BMJ Open Qual. 2019;8(2):e000593. doi:10.1136/bmjoq-2018-000593. Copy Citation…
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