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  1. Preventing wrong site, procedure, and patient events using a common cause analysis. | PSNet

    psnet.ahrq.gov/issue/preventing-wrong-site-procedure-and-patient-events-using-common-cause-analysis
    October 03, 2017 - Study Preventing wrong site, procedure, and patient events using a common cause analysis. Citation Text: Mallett R, Conroy M, Saslaw LZ, et al. Preventing wrong site, procedure, and patient events using a common cause analysis. Am J Med Qual. 2012;27(1):21-9. doi:10.1177/10628606114120…

  2. I-PASS Mentored Implementation Handoff Curriculum: implementation guide and resources. | PSNet

    psnet.ahrq.gov/issue/i-pass-mentored-implementation-handoff-curriculum-implementation-guide-and-resources
    November 16, 2022 - Commentary I-PASS Mentored Implementation Handoff Curriculum: implementation guide and resources. Citation Text: O'Toole JK, Starmer AJ, Calaman S, et al. I-PASS Mentored Implementation Handoff Curriculum: implementation guide and resources. MedEdPORTAL. 2018;14(1):10736. doi:10.15766/me…

  3. Near miss research in the healthcare system: a scoping review. | PSNet

    psnet.ahrq.gov/issue/near-miss-research-healthcare-system-scoping-review
    July 15, 2020 - Review Near miss research in the healthcare system: a scoping review. Citation Text: Feng T-ting, Zhang X, Tan L-ling, et al. Near miss research in the healthcare system: a scoping review. J Nurs Adm. 2022;52(3):160-166. doi:10.1097/nna.0000000000001124. Copy Citation Format: …

  4. Virtual patients designed for training against medical error: exploring the impact of decision-making on learner motivation. | PSNet

    psnet.ahrq.gov/issue/virtual-patients-designed-training-against-medical-error-exploring-impact-decision-making
    May 15, 2024 - Study Virtual patients designed for training against medical error: exploring the impact of decision-making on learner motivation. Citation Text: Woodham LA, Round J, Stenfors T, et al. Virtual patients designed for training against medical error: Exploring the impact of decision-making …

  5. Compliance with guidelines to prevent surgical site infections: as simple as 1-2-3? | PSNet

    psnet.ahrq.gov/issue/compliance-guidelines-prevent-surgical-site-infections-simple-1-2-3
    January 21, 2019 - Study Compliance with guidelines to prevent surgical site infections: as simple as 1-2-3? Citation Text: Meeks DW, Lally KP, Carrick MM, et al. Compliance with guidelines to prevent surgical site infections: As simple as 1-2-3? Am J Surg. 2011;201(1):76-83. doi:10.1016/j.amjsurg.2009.0…

  6. The Limits of Safety: Organizations, Accidents and Nuclear Weapons. | PSNet

    psnet.ahrq.gov/issue/limits-safety-organizations-accidents-and-nuclear-weapons
    July 28, 2013 - Book/Report Classic The Limits of Safety: Organizations, Accidents and Nuclear Weapons. Citation Text: The Limits of Safety: Organizations, Accidents and Nuclear Weapons. Sagan SD. Princeton NJ: Princeton University Press; 1993. ISBN: 9780691032214. Copy Cit…

  7. Improving the quality of health care: what's taking so long? | PSNet

    psnet.ahrq.gov/issue/improving-quality-health-care-whats-taking-so-long
    April 06, 2016 - Commentary Classic Improving the quality of health care: what's taking so long? Citation Text: Chassin MR. Improving The Quality Of Health Care: What’s Taking So Long? Health Aff. 2013;32(10):1761-1765. doi:10.1377/hlthaff.2013.0809. Copy Citation Format: …

  8. Low literacy impairs comprehension of prescription drug warning labels. | PSNet

    psnet.ahrq.gov/issue/low-literacy-impairs-comprehension-prescription-drug-warning-labels
    January 21, 2009 - Study Low literacy impairs comprehension of prescription drug warning labels. Citation Text: Davis TC, Wolf MS, Bass PF, et al. Low literacy impairs comprehension of prescription drug warning labels. J Gen Intern Med. 2006;21(8):847-51. Copy Citation Format: Google Schola…

  9. Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration. | PSNet

    psnet.ahrq.gov/issue/patient-misidentification-laboratory-medicine-qualitative-analysis-227-root-cause-analysis
    August 28, 2024 - Study Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration. Citation Text: Dunn EJ, Moga PJ. Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis …

  10. Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue. | PSNet

    psnet.ahrq.gov/issue/academic-year-end-transfers-outpatients-outgoing-incoming-residents-unaddressed-patient
    January 27, 2016 - Commentary Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue. Citation Text: Young JQ, Wachter R. Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue. JAMA.…

  11. Positive predictive value of the AHRQ accidental puncture or laceration patient safety indicator. | PSNet

    psnet.ahrq.gov/issue/positive-predictive-value-ahrq-accidental-puncture-or-laceration-patient-safety-indicator
    April 03, 2017 - Slideset Positive predictive value of the AHRQ accidental puncture or laceration patient safety indicator. Citation Text: Utter GH, Zrelak PA, Baron R, et al. Positive predictive value of the AHRQ accidental puncture or laceration patient safety indicator. Ann Surg. 2009;250(6):1041-5.…

  12. Diagnostic error in the pediatric hospital: a narrative review. | PSNet

    psnet.ahrq.gov/issue/diagnostic-error-pediatric-hospital-narrative-review
    November 16, 2022 - Review Diagnostic error in the pediatric hospital: a narrative review. Citation Text: Sawicki JG, Nystrom DT, Purtell R, et al. Diagnostic error in the pediatric hospital: a narrative review. Hosp Pract (1995). 2021;49((supp1):437-444. doi:10.1080/21548331.2021.2004040. Copy Citation …

  13. Curriculum development and implementation of a national interprofessional fellowship in patient safety. | PSNet

    psnet.ahrq.gov/issue/curriculum-development-and-implementation-national-interprofessional-fellowship-patient
    November 18, 2016 - Commentary Curriculum development and implementation of a national interprofessional fellowship in patient safety. Citation Text: Watts B, Williams L, Mills PD, et al. Curriculum Development and Implementation of a National Interprofessional Fellowship in Patient Safety. J Patient Saf. 2…

  14. Racism and electronic health records (EHRs): perspectives for research and practice. | PSNet

    psnet.ahrq.gov/issue/racism-and-electronic-health-records-ehrs-perspectives-research-and-practice
    March 27, 2024 - Commentary Racism and electronic health records (EHRs): perspectives for research and practice. Citation Text: Emani S, Rodriguez JA, Bates DW. Racism and electronic health records (EHRs): perspectives for research and practice. J Am Med Inform Assoc. 2023;30(5):995-999. doi:10.1093/jami…

  15. The weekend effect in hospitalized patients: a meta-analysis. | PSNet

    psnet.ahrq.gov/issue/weekend-effect-hospitalized-patients-meta-analysis
    September 23, 2020 - Review The weekend effect in hospitalized patients: a meta-analysis. Citation Text: Pauls LA, Johnson-Paben R, McGready J, et al. The Weekend Effect in Hospitalized Patients: A Meta-Analysis. J Hosp Med. 2017;12(9):760-766. doi:10.12788/jhm.2815. Copy Citation Format: DOI G…

  16. Adaptation and implementation of the WHO Safe Childbirth Checklist around the world. | PSNet

    psnet.ahrq.gov/issue/adaptation-and-implementation-who-safe-childbirth-checklist-around-world
    March 17, 2021 - Study Adaptation and implementation of the WHO Safe Childbirth Checklist around the world. Citation Text: Molina RL, Benski A-C, Bobanski L, et al. Adaptation and implementation of the WHO Safe Childbirth Checklist around the world. Implement Sci Commun. 2021;2(1):76. doi:10.1186/s43058-…

  17. Clinicians' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. | PSNet

    psnet.ahrq.gov/issue/clinicians-expectations-benefits-and-harms-treatments-screening-and-tests-systematic-review
    May 05, 2021 - Review Clinicians' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. Citation Text: Hoffmann TC, Del Mar C. Clinicians' Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review. JAMA Intern Med. 2017;17…

  18. A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings. | PSNet

    psnet.ahrq.gov/issue/qi-initiative-implementing-patient-handoff-checklist-pediatric-hospitalist-attendings
    July 28, 2021 - Commentary A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings. Citation Text: Lo H-Y, Mullan PC, Lye C, et al. A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings. BMJ Qual Improv Rep. 2016;5(1). doi:1…

  19. Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. | PSNet

    psnet.ahrq.gov/issue/interventions-reduction-prescribed-opioid-use-chronic-non-cancer-pain
    April 04, 2011 - Review Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. Citation Text: Eccleston C, Fisher E, Thomas KH, et al. Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. Cochrane Database Syst Rev. 2017;11:CD010323. doi:10.10…

  20. Suffering in silence: medical error and its impact on health care providers. | PSNet

    psnet.ahrq.gov/issue/suffering-silence-medical-error-and-its-impact-health-care-providers
    December 12, 2014 - Review Suffering in silence: medical error and its impact on health care providers. Citation Text: Robertson JJ, Long B. Suffering in Silence: Medical Error and its Impact on Health Care Providers. J Emerg Med. 2018;54(4). doi:10.1016/j.jemermed.2017.12.001. Copy Citation Format: …
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