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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. Medication error reporting in rural critical access hospitals in the North Dakota Telepharmacy Project. | PSNet

    psnet.ahrq.gov/issue/medication-error-reporting-rural-critical-access-hospitals-north-dakota-telepharmacy-project
    October 17, 2012 - Study Medication error reporting in rural critical access hospitals in the North Dakota Telepharmacy Project. Citation Text: Scott DM, Friesner DL, Rathke AM, et al. Medication error reporting in rural critical access hospitals in the North Dakota Telepharmacy Project. Am J Health Syst …

  3. Ambulatory medication reconciliation: using a collaborative approach to process improvement at an academic medical center. | PSNet

    psnet.ahrq.gov/issue/ambulatory-medication-reconciliation-using-collaborative-approach-process-improvement
    December 04, 2019 - Study Ambulatory medication reconciliation: using a collaborative approach to process improvement at an academic medical center. Citation Text: Keogh C, Kachalia A, Fiumara K, et al. Ambulatory Medication Reconciliation: Using a Collaborative Approach to Process Improvement at an Academi…

  4. Diagnostic disparities and strategies for enhancing diagnostic equity in hospital medicine. | PSNet

    psnet.ahrq.gov/issue/diagnostic-disparities-and-strategies-enhancing-diagnostic-equity-hospital-medicine
    April 12, 2023 - Commentary Diagnostic disparities and strategies for enhancing diagnostic equity in hospital medicine. Citation Text: Raffel KE, Gershanik EF, Ranji SR. Diagnostic disparities and strategies for enhancing diagnostic equity in hospital medicine. J Hosp Med. 2025;20(1):71-74. doi:10.1002/j…

  5. Applying root cause analysis to improve patient safety: decreasing falls in postpartum women. | PSNet

    psnet.ahrq.gov/issue/applying-root-cause-analysis-improve-patient-safety-decreasing-falls-postpartum-women
    August 04, 2021 - Study Applying root cause analysis to improve patient safety: decreasing falls in postpartum women. Citation Text: Chen K-H, Chen L-R, Su S. Applying root cause analysis to improve patient safety: decreasing falls in postpartum women. Qual Saf Health Care. 2010;19(2):138-43. doi:10.113…

  6. Current State of Diagnostic Safety: Implications for Research, Practice, and Policy. | PSNet

    psnet.ahrq.gov/issue/current-state-diagnostic-safety-implications-research-practice-and-policy
    August 07, 2024 - Book/Report Current State of Diagnostic Safety: Implications for Research, Practice, and Policy. Citation Text: Current State of Diagnostic Safety: Implications for Research, Practice, and Policy. Khan S, Cholankeril R, Sloane J, et al. Rockville, MD: Agency for Healthcare Research and Q…

  7. The things we carry: the scope and impact of second victim syndrome. | PSNet

    psnet.ahrq.gov/issue/things-we-carry-scope-and-impact-second-victim-syndrome
    November 12, 2014 - Commentary The things we carry: the scope and impact of second victim syndrome. Citation Text: Nosanov L, Elseth AJ, Maxwell J, et al. The things we carry: the scope and impact of second victim syndrome. Am J Surg. 2023;226(5):726-728. doi:10.1016/j.amjsurg.2023.06.035. Copy Citation …

  8. Racial and ethnic harm in patient care is a patient safety issue. | PSNet

    psnet.ahrq.gov/issue/racial-and-ethnic-harm-patient-care-patient-safety-issue
    October 21, 2020 - Commentary Racial and ethnic harm in patient care is a patient safety issue. Citation Text: Rosario N, Kiles TM, M. Jewell T'B, et al. Racial and ethnic harm in patient care is a patient safety issue. Res Social Adm Pharm. 2024;20(7):670-677. doi:10.1016/j.sapharm.2024.04.012. Copy Cit…

  9. Anticoagulant medication errors in hospitals and primary care: a cross-sectional study. | PSNet

    psnet.ahrq.gov/issue/anticoagulant-medication-errors-hospitals-and-primary-care-cross-sectional-study
    August 18, 2010 - Study Anticoagulant medication errors in hospitals and primary care: a cross-sectional study. Citation Text: Dreijer AR, Diepstraten J, Bukkems VE, et al. Anticoagulant medication errors in hospitals and primary care: a cross-sectional study. Int J Qual Health Care. 2019;31(5):346-352. d…

  10. Preventable and non-preventable adverse drug events in hospitalized patients: a prospective chart review in the Netherlands. | PSNet

    psnet.ahrq.gov/issue/preventable-and-non-preventable-adverse-drug-events-hospitalized-patients-prospective-chart
    March 04, 2011 - Study Preventable and non-preventable adverse drug events in hospitalized patients: a prospective chart review in the Netherlands. Citation Text: Dequito AB, Mol PGM, van Doormaal J, et al. Preventable and non-preventable adverse drug events in hospitalized patients: a prospective char…

  11. A randomized trial of nighttime physician staffing in an intensive care unit. | PSNet

    psnet.ahrq.gov/issue/randomized-trial-nighttime-physician-staffing-intensive-care-unit
    September 23, 2020 - Study A randomized trial of nighttime physician staffing in an intensive care unit. Citation Text: Kerlin MP, Small DS, Cooney E, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;368(23):2201-9. doi:10.1056/NEJMoa1302854. Copy Ci…

  12. A safety culture transformation: its effects at a children's hospital. | PSNet

    psnet.ahrq.gov/issue/safety-culture-transformation-its-effects-childrens-hospital
    November 04, 2014 - Study A safety culture transformation: its effects at a children's hospital. Citation Text: Peterson TH, Teman SF, Connors RH. A safety culture transformation: its effects at a children's hospital. J Patient Saf. 2012;8(3):125-30. doi:10.1097/PTS.0b013e31824bd744. Copy Citation F…

  13. Composite measures for profiling hospitals on bariatric surgery performance. | PSNet

    psnet.ahrq.gov/issue/composite-measures-profiling-hospitals-bariatric-surgery-performance
    January 31, 2013 - Study Composite measures for profiling hospitals on bariatric surgery performance. Citation Text: Dimick JB, Birkmeyer NJ, Finks JF, et al. Composite measures for profiling hospitals on bariatric surgery performance. JAMA Surg. 2014;149(1):10-6. doi:10.1001/jamasurg.2013.4109. Copy Cit…

  14. Evidence-based organization and patient safety strategies in European hospitals. | PSNet

    psnet.ahrq.gov/issue/evidence-based-organization-and-patient-safety-strategies-european-hospitals
    January 20, 2016 - Study Evidence-based organization and patient safety strategies in European hospitals. Citation Text: Suñol R, Wagner C, Arah OA, et al. Evidence-based organization and patient safety strategies in European hospitals. Int J Qual Health Care. 2014;26 Suppl 1:47-55. doi:10.1093/intqhc/mzu0…

  15. A decade after Francis: is the NHS safer and more open? | PSNet

    psnet.ahrq.gov/issue/decade-after-francis-nhs-safer-and-more-open
    September 29, 2021 - Commentary A decade after Francis: is the NHS safer and more open? Citation Text: Martin G, Stanford S, Dixon-Woods M. A decade after Francis: is the NHS safer and more open? BMJ. 2023;380:513. doi:10.1136/bmj.p513. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3…

  16. Protecting children from iatrogenic harm during COVID19 pandemic. | PSNet

    psnet.ahrq.gov/issue/protecting-children-iatrogenic-harm-during-covid19-pandemic
    December 02, 2020 - Commentary Protecting children from iatrogenic harm during COVID19 pandemic. Citation Text: Camporesi A, Díaz‐Rubio F, Carroll CL, et al. Protecting children from iatrogenic harm during COVID19 pandemic. J Paediatr Child Health. 2020;56(7):1010-1012. doi:10.1111/jpc.14989. Copy Citatio…

  17. Outcomes of missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis, and sepsis in five pediatric hospitals. | PSNet

    psnet.ahrq.gov/issue/outcomes-missed-diagnosis-pediatric-appendicitis-new-onset-diabetic-ketoacidosis-and-sepsis
    September 29, 2021 - Study Outcomes of missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis, and sepsis in five pediatric hospitals. Citation Text: Michelson KA, Bachur RG, Grubenhoff JA, et al. Outcomes of missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis, an…

  18. Developing tools to enhance the adaptive capacity (Safety II) of health care providers at a children's hospital. | PSNet

    psnet.ahrq.gov/issue/developing-tools-enhance-adaptive-capacity-safety-ii-health-care-providers-childrens-hospital
    July 22, 2020 - Commentary Developing tools to enhance the adaptive capacity (Safety II) of health care providers at a children's hospital. Citation Text: Bartman T, Merandi J, Maa T, et al. Developing tools to enhance the adaptive capacity (Safety II) of health care providers at a children's hospital. …

  19. Comparative issues in aviation and surgical crew resource management: (1) are we too solution focused? | PSNet

    psnet.ahrq.gov/issue/comparative-issues-aviation-and-surgical-crew-resource-management-1-are-we-too-solution
    October 30, 2013 - Commentary Comparative issues in aviation and surgical crew resource management: (1) are we too solution focused? Citation Text: Hunt GJF, Callaghan KSN. COMPARATIVE ISSUES IN AVIATION AND SURGICAL CREW RESOURCE MANAGEMENT: (1) ARE WE TOO SOLUTION FOCUSED? ANZ J Surg. 2008;78(8). doi:1…

  20. Visual illusions in radiology: untrue perceptions in medical images and their implications for diagnostic accuracy. | PSNet

    psnet.ahrq.gov/issue/visual-illusions-radiology-untrue-perceptions-medical-images-and-their-implications
    July 06, 2022 - Commentary Visual illusions in radiology: untrue perceptions in medical images and their implications for diagnostic accuracy. Citation Text: Alexander RG, Yazdanie F, Waite S, et al. Visual illusions in radiology: untrue perceptions in medical images and their implications for diagnosti…
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