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  1. Health care huddles: managing complexity to achieve high reliability. | PSNet

    psnet.ahrq.gov/issue/health-care-huddles-managing-complexity-achieve-high-reliability
    November 17, 2015 - Study Health care huddles: managing complexity to achieve high reliability. Citation Text: Provost SM, Lanham H, Leykum LK, et al. Health care huddles: managing complexity to achieve high reliability. Health Care Manage Rev. 2015;40(1):2-12. doi:10.1097/HMR.0000000000000009. Copy Citat…

  2. Psychometric properties of the AHRQ Community Pharmacy Survey on Patient Safety Culture: a factor analysis. | PSNet

    psnet.ahrq.gov/issue/psychometric-properties-ahrq-community-pharmacy-survey-patient-safety-culture-factor-analysis
    February 07, 2018 - Study Psychometric properties of the AHRQ Community Pharmacy Survey on Patient Safety Culture: a factor analysis. Citation Text: Aboneh EA, Look KA, Stone JA, et al. Psychometric properties of the AHRQ Community Pharmacy Survey on Patient Safety Culture: a factor analysis. BMJ Qual Saf. …

  3. A systematic review of falls in hospital for patients with communication disability: highlighting an invisible population. | PSNet

    psnet.ahrq.gov/issue/systematic-review-falls-hospital-patients-communication-disability-highlighting-invisible
    April 15, 2016 - Review A systematic review of falls in hospital for patients with communication disability: highlighting an invisible population. Citation Text: Hemsley B, Steel J, Worrall L, et al. A systematic review of falls in hospital for patients with communication disability: Highlighting an invi…

  4. Patient and physician experience with interhospital transfer: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/patient-and-physician-experience-interhospital-transfer-qualitative-study
    April 12, 2023 - Study Patient and physician experience with interhospital transfer: a qualitative study. Citation Text: Mueller SK, Shannon E, Dalal A, et al. Patient and Physician Experience with Interhospital Transfer: A Qualitative Study. J Patient Saf. 2021;17(8):e752-e757. doi:10.1097/PTS.000000000…

  5. Safe use of electronic health records and health information technology systems: trust but verify. | PSNet

    psnet.ahrq.gov/issue/safe-use-electronic-health-records-and-health-information-technology-systems-trust-verify
    August 02, 2015 - Study Safe use of electronic health records and health information technology systems: trust but verify. Citation Text: Denham CR, Classen D, Swenson SJ, et al. Safe use of electronic health records and health information technology systems: trust but verify. J Patient Saf. 2013;9(4):17…

  6. The influence of formulation and medicine delivery system on medication administration errors in care homes for older people. | PSNet

    psnet.ahrq.gov/issue/influence-formulation-and-medicine-delivery-system-medication-administration-errors-care
    March 23, 2011 - Study The influence of formulation and medicine delivery system on medication administration errors in care homes for older people. Citation Text: Alldred DP, Standage C, Fletcher O, et al. The influence of formulation and medicine delivery system on medication administration errors in…

  7. Evaluation of an anonymous system to report medical errors in pediatric inpatients. | PSNet

    psnet.ahrq.gov/issue/evaluation-anonymous-system-report-medical-errors-pediatric-inpatients
    April 30, 2014 - Study Evaluation of an anonymous system to report medical errors in pediatric inpatients. Citation Text: Taylor JA, Brownstein D, Klein EJ, et al. Evaluation of an anonymous system to report medical errors in pediatric inpatients. J Hosp Med. 2007;2(4):226-33. Copy Citation Forma…

  8. Prioritising the prevention of medication handling errors. | PSNet

    psnet.ahrq.gov/issue/prioritising-prevention-medication-handling-errors
    October 22, 2008 - Study Prioritising the prevention of medication handling errors. Citation Text: Bertsche T, Niemann D, Mayer Y, et al. Prioritising the prevention of medication handling errors. Pharm World Sci. 2008;30(6):907-15. doi:10.1007/s11096-008-9250-3. Copy Citation Format: DOI…

  9. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. | PSNet

    psnet.ahrq.gov/issue/communication-failures-patient-sign-out-and-suggestions-improvement-critical-incident
    April 16, 2008 - Study Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Citation Text: Arora VM, Johnson JK, Lovinger D, et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Hea…

  10. Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic medical record. | PSNet

    psnet.ahrq.gov/issue/failure-recognize-newly-identified-aortic-dilations-health-care-system-advanced-electronic
    August 04, 2021 - Study Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic medical record. Citation Text: Gordon JRS, Wahls TL, Carlos RC, et al. Failure to recognize newly identified aortic dilations in a health care system with an advanced electro…

  11. Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children. | PSNet

    psnet.ahrq.gov/issue/drug-formulations-require-potentially-inaccurate-volumes-prepare-doses-infants-and-children
    April 22, 2011 - Study Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children. Citation Text: Uppal N, Yasseen B, Seto W, et al. Drug formulations that require less than 0.1 mL of stock solution to prepare doses for infants and children. CMAJ. 2011;183(4…

  12. Management of arterial lines and blood sampling in intensive care: a threat to patient safety. | PSNet

    psnet.ahrq.gov/issue/management-arterial-lines-and-blood-sampling-intensive-care-threat-patient-safety
    November 12, 2014 - Study Management of arterial lines and blood sampling in intensive care: a threat to patient safety. Citation Text: Leslie RA, Gouldson S, Habib N, et al. Management of arterial lines and blood sampling in intensive care: a threat to patient safety. Anaesthesia. 2013;68(11). doi:10.1111…

  13. Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular examinations for orthopedic trauma patients. | PSNet

    psnet.ahrq.gov/issue/diagnostic-errors-orthopedic-surgery-evaluation-resident-documentation-neurovascular
    December 31, 2014 - Study Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular examinations for orthopedic trauma patients. Citation Text: Tan EW, Ting BL, Jia X, et al. Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular …

  14. Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. | PSNet

    psnet.ahrq.gov/issue/prospective-memory-icu-effect-visual-cues-task-execution-representative-simulation
    April 24, 2018 - Study Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. Citation Text: Grundgeiger T, Sanderson PM, Orihuela B, et al. Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. Ergo…

  15. Impact of resident workload and handoff training on patient outcomes. | PSNet

    psnet.ahrq.gov/issue/impact-resident-workload-and-handoff-training-patient-outcomes
    April 12, 2023 - Study Impact of resident workload and handoff training on patient outcomes. Citation Text: Mueller SK, Call S, McDonald FS, et al. Impact of resident workload and handoff training on patient outcomes. Am J Med. 2012;125(1):104-10. doi:10.1016/j.amjmed.2011.09.005. Copy Citation F…

  16. E-prescribing errors in community pharmacies: exploring consequences and contributing factors. | PSNet

    psnet.ahrq.gov/issue/e-prescribing-errors-community-pharmacies-exploring-consequences-and-contributing-factors
    January 07, 2015 - Study E-prescribing errors in community pharmacies: exploring consequences and contributing factors. Citation Text: Odukoya OK, Stone JA, Chui MA. E-prescribing errors in community pharmacies: exploring consequences and contributing factors. Int J Med Inform. 2014;83(6):427-37. doi:10.10…

  17. Electronic health record use and the quality of ambulatory care in the United States. | PSNet

    psnet.ahrq.gov/issue/electronic-health-record-use-and-quality-ambulatory-care-united-states
    May 31, 2023 - Study Electronic health record use and the quality of ambulatory care in the United States. Citation Text: Linder JA, Ma J, Bates DW, et al. Electronic health record use and the quality of ambulatory care in the United States. Arch Intern Med. 2007;167(13):1400-5. Copy Citation F…

  18. Correlation between hospital rating agencies' data: an analysis and recommendation. | PSNet

    psnet.ahrq.gov/issue/correlation-between-hospital-rating-agencies-data-analysis-and-recommendation
    April 05, 2023 - Study Correlation between hospital rating agencies' data: an analysis and recommendation. Citation Text: Sondheim SE, Mattie A, Vigil J, et al. Correlation between hospital rating agencies’ data: An analysis and recommendation. J Healthc Risk Manag. 2020;40(3):18-24. doi:10.1002/jhrm.214…

  19. An observational study of changes to long-term medication after admission to an intensive care unit. | PSNet

    psnet.ahrq.gov/issue/observational-study-changes-long-term-medication-after-admission-intensive-care-unit
    January 06, 2018 - Study An observational study of changes to long-term medication after admission to an intensive care unit. Citation Text: Campbell AJ, Bloomfield R, Noble DW. An observational study of changes to long-term medication after admission to an intensive care unit. Anaesthesia. 2006;61(11):1…

  20. The problem with 'My Five Moments for Hand Hygiene'. | PSNet

    psnet.ahrq.gov/issue/problem-my-five-moments-hand-hygiene
    September 09, 2020 - Commentary The problem with 'My Five Moments for Hand Hygiene'. Citation Text: Gould D, Purssell E, Jeanes A, et al. The problem with ‘My Five Moments for Hand Hygiene’. BMJ Qual Saf. 2022;31(4):322-326. doi:10.1136/bmjqs-2020-011911. Copy Citation Format: DOI Google Schola…
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