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  1. Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem. | PSNet

    psnet.ahrq.gov/issue/understanding-barriers-physician-error-reporting-and-disclosure-systemic-approach-systemic
    January 12, 2022 - Review Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem. Citation Text: Perez B, Knych SA, Weaver SJ, et al. Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem…

  2. Medication reconciliation at admission and discharge: an analysis of prevalence and associated risk factors. | PSNet

    psnet.ahrq.gov/issue/medication-reconciliation-admission-and-discharge-analysis-prevalence-and-associated-risk
    December 02, 2020 - Study Medication reconciliation at admission and discharge: an analysis of prevalence and associated risk factors. Citation Text: Belda-Rustarazo S, Cantero-Hinojosa J, Salmeron-García A, et al. Medication reconciliation at admission and discharge: an analysis of prevalence and associate…

  3. 'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports. | PSNet

    psnet.ahrq.gov/issue/connecting-dots-leveraging-visual-analytics-make-sense-patient-safety-event-reports
    May 29, 2024 - Commentary 'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports. Citation Text: Ratwani RM, Fong A. 'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports. J Am Med Inform Assoc. 2015;22(2):312-7. doi:1…

  4. Clinical outcomes from the use of Medication Report when elderly patients are discharged from hospital. | PSNet

    psnet.ahrq.gov/issue/clinical-outcomes-use-medication-report-when-elderly-patients-are-discharged-hospital
    January 27, 2012 - Study Clinical outcomes from the use of Medication Report when elderly patients are discharged from hospital. Citation Text: Midlöv P, Deierborg E, Holmdahl L, et al. Clinical outcomes from the use of Medication Report when elderly patients are discharged from hospital. Pharm World S…

  5. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. | PSNet

    psnet.ahrq.gov/issue/prescriber-barriers-and-enablers-minimising-potentially-inappropriate-medications-adults
    September 23, 2020 - Review Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. Citation Text: Anderson K, Stowasser D, Freeman C, et al. Prescriber barriers and enablers to minimising potentially inappropriate medication…

  6. Differentiating between detrimental and beneficial interruptions: a mixed-methods study. | PSNet

    psnet.ahrq.gov/issue/differentiating-between-detrimental-and-beneficial-interruptions-mixed-methods-study
    May 03, 2017 - Study Differentiating between detrimental and beneficial interruptions: a mixed-methods study. Citation Text: Myers RA, McCarthy MC, Whitlatch A, et al. Differentiating between detrimental and beneficial interruptions: a mixed-methods study. BMJ Qual Saf. 2016;25(11):881-888. doi:10.1136…

  7. The high-reliability pediatric intensive care unit. | PSNet

    psnet.ahrq.gov/issue/high-reliability-pediatric-intensive-care-unit
    July 16, 2014 - Review The high-reliability pediatric intensive care unit. Citation Text: Niedner M, Muething S, Sutcliffe K. The high-reliability pediatric intensive care unit. Pediatr Clin North Am. 2013;60(3):563-80. doi:10.1016/j.pcl.2013.02.005. Copy Citation Format: DOI Google Schol…

  8. Medication safety in older adults: home-based practice patterns. | PSNet

    psnet.ahrq.gov/issue/medication-safety-older-adults-home-based-practice-patterns
    June 30, 2011 - Study Medication safety in older adults: home-based practice patterns. Citation Text: Metlay JP, Cohen A, Polsky D, et al. Medication safety in older adults: home-based practice patterns. J Am Geriatr Soc. 2005;53(6):976-982. Copy Citation Format: Google Scholar PubMed Bi…

  9. Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration. | PSNet

    psnet.ahrq.gov/issue/comparing-errors-ed-computer-assisted-vs-conventional-pediatric-drug-dosing-and
    November 22, 2017 - Study Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration. Citation Text: Yamamoto LG, Kanemori J. Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration. Am J Emerg Med. 2010;28(5):588-92. doi:10.…

  10. Quiet please! Drug round tabards: are they effective and accepted? A mixed method study. | PSNet

    psnet.ahrq.gov/issue/quiet-please-drug-round-tabards-are-they-effective-and-accepted-mixed-method-study
    May 19, 2018 - Study Quiet please! Drug round tabards: are they effective and accepted? A mixed method study. Citation Text: Verweij L, Smeulers M, Maaskant JM, et al. Quiet please! Drug round tabards: are they effective and accepted? A mixed method study. J Nurs Scholarsh. 2014;46(5):340-8. doi:10.111…

  11. Doctors and dentists still flooding U.S. with opioid prescriptions. | PSNet

    psnet.ahrq.gov/issue/doctors-and-dentists-still-flooding-us-opioid-prescriptions
    October 13, 2018 - Newspaper/Magazine Article Doctors and dentists still flooding U.S. with opioid prescriptions. Citation Text: Mann B. Doctors and dentists still flooding U.S. with opioid prescriptions. National Public Radio. 2020;July 17. Copy Citation Format: Google Scholar BibTeX EndNote…

  12. The impact of the built environment on patient falls in hospital rooms: an integrative review. | PSNet

    psnet.ahrq.gov/issue/impact-built-environment-patient-falls-hospital-rooms-integrative-review
    July 27, 2022 - Review The impact of the built environment on patient falls in hospital rooms: an integrative review. Citation Text: Pati D, Valipoor S, Lorusso L, et al. The impact of the built environment on patient falls in hospital rooms: an integrative review. J Patient Saf. 2021;17(4):273-281. doi…

  13. A review of the literature examining linkages between organizational factors, medical errors, and patient safety. | PSNet

    psnet.ahrq.gov/issue/review-literature-examining-linkages-between-organizational-factors-medical-errors-and
    June 24, 2010 - Review A review of the literature examining linkages between organizational factors, medical errors, and patient safety. Citation Text: Hoff T, Jameson L, Hannan E, et al. A review of the literature examining linkages between organizational factors, medical errors, and patient safety. …

  14. Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare. | PSNet

    psnet.ahrq.gov/issue/near-misses-are-opportunity-improve-patient-safety-adapting-strategies-high-reliability
    July 01, 2011 - Review Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare. Citation Text: Van Spall H, Kassam A, Tollefson TT. Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability orga…

  15. Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit. | PSNet

    psnet.ahrq.gov/issue/effect-lean-intervention-improve-safety-processes-and-outcomes-surgical-emergency-unit
    January 04, 2010 - Study Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit. Citation Text: McCulloch P, Kreckler S, New S, et al. Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit. BMJ. 2010;341:c5469.…

  16. Building a safety net. | PSNet

    psnet.ahrq.gov/issue/building-safety-net
    December 21, 2009 - Newspaper/Magazine Article Building a safety net. Citation Text: Rogoski RR. Building a safety net. By leveraging huge amounts of data and applying it to a wide array of projects and purposes, hospitals stay focused on patient safety and make headway. Health management technology. 2006…

  17. Assessment of the use of patient vital sign data for preventing misidentification and medical errors. | PSNet

    psnet.ahrq.gov/issue/assessment-use-patient-vital-sign-data-preventing-misidentification-and-medical-errors
    February 16, 2022 - Commentary Assessment of the use of patient vital sign data for preventing misidentification and medical errors. Citation Text: Maul J, Straub J. Assessment of the use of patient vital sign data for preventing misidentification and medical errors. Healthcare (Basel). 2022;10(12):2440. do…

  18. Developing and pilot testing practical measures of preanalytic surgical specimen identification defects. | PSNet

    psnet.ahrq.gov/issue/developing-and-pilot-testing-practical-measures-preanalytic-surgical-specimen-identification
    June 16, 2011 - Study Developing and pilot testing practical measures of preanalytic surgical specimen identification defects. Citation Text: Bixenstine PJ, Zarbo RJ, Holzmueller CG, et al. Developing and pilot testing practical measures of preanalytic surgical specimen identification defects. Am J M…

  19. Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. | PSNet

    psnet.ahrq.gov/issue/risk-factors-retained-surgical-items-meta-analysis-and-proposed-risk-stratification-system
    January 18, 2013 - Study Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. Citation Text: Moffatt-Bruce SD, Cook CH, Steinberg SM, et al. Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. J Surg Res. 2014;190(…

  20. From HRO to HERO: making health equity a core system capability. | PSNet

    psnet.ahrq.gov/issue/hro-hero-making-health-equity-core-system-capability
    September 30, 2020 - Commentary From HRO to HERO: making health equity a core system capability. Citation Text: Moy E, Hausmann LRM, Clancy CM. From HRO to HERO: making health equity a core system capability. Am J Med Qual. 2022;37(1):81-83. doi:10.1097/jmq.0000000000000020. Copy Citation Format: …
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