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Hospital Survey on Patient Safety Culture: 2018 User Database Report. | PSNet

psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2018-user-database-report

May 02, 2018 - Book/Report Hospital Survey on Patient Safety Culture: 2018 User Database Report. Citation Text: Hospital Survey on Patient Safety Culture: 2018 User Database Report. Famolaro T, Yount N, Hare, R, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2018. AHRQ Publicat…

Measuring team hierarchy during high-stakes clinical decision making: development and validation of a new behavioral observation method. | PSNet

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April 05, 2023 - Study Measuring team hierarchy during high-stakes clinical decision making: development and validation of a new behavioral observation method. Citation Text: Johansson AC, Manago B, Sell J, et al. Measuring team hierarchy during high-stakes clinical decision making: development and valid…

Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center. | PSNet

psnet.ahrq.gov/issue/one-pen-one-patient-achievable-hospital-quality-improvement-project-reduce-risks-inadvertent

April 10, 2024 - Study Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center. Citation Text: Ho S, Stamm R, Hibbs M, et al. Is One-Pen, One-Patient Achievable in the Hospital? A Quality Impr…

Sources of nurse-sensitive inpatient safety improvement. | PSNet

psnet.ahrq.gov/issue/sources-nurse-sensitive-inpatient-safety-improvement

July 07, 2021 - Study Sources of nurse-sensitive inpatient safety improvement. Citation Text: Dynan L, Smith RB. Sources of nurse‐sensitive inpatient safety improvement. Health Serv Res. 2022;57(6):1235-1246. doi:10.1111/1475-6773.13979. Copy Citation Format: DOI Google Scholar BibTeX EndN…

Intervening in interruptions: what exactly is the risk we are trying to manage? | PSNet

psnet.ahrq.gov/issue/intervening-interruptions-what-exactly-risk-we-are-trying-manage

July 20, 2022 - Review Intervening in interruptions: what exactly is the risk we are trying to manage? Citation Text: Gao J, Rae AJ, Dekker SWA. Intervening in Interruptions: What Exactly Is the Risk We Are Trying to Manage? J Patient Saf. 2021;17(7):e684-e688. doi:10.1097/PTS.0000000000000429. Copy C…

Importance of prevention and early intervention of adverse events in pediatric cardiac catheterization: a review of three years of experience. | PSNet

psnet.ahrq.gov/issue/importance-prevention-and-early-intervention-adverse-events-pediatric-cardiac-catheterization

March 24, 2019 - Study Importance of prevention and early intervention of adverse events in pediatric cardiac catheterization: a review of three years of experience. Citation Text: Huang Y-C, Chang J-S, Lai Y-C, et al. Importance of prevention and early intervention of adverse events in pediatric cardi…

High-risk medication errors: insight from the UK National Reporting and Learning System. | PSNet

psnet.ahrq.gov/issue/high-risk-medication-errors-insight-uk-national-reporting-and-learning-system

January 12, 2022 - Study High-risk medication errors: insight from the UK National Reporting and Learning System. Citation Text: Alrowily A, Alfaraidy K, Almutairi S, et al. High-risk medication errors: Insight from the UK National Reporting and learning system. Explor Res Clin Soc Pharm. 2025;17:100531. d…

Using simulation to augment root cause analysis for patient safety incidents at a tertiary care women's and children's hospital: a qualitative feasibility study. | PSNet

psnet.ahrq.gov/issue/using-simulation-augment-root-cause-analysis-patient-safety-incidents-tertiary-care-womens

January 22, 2025 - Study Using simulation to augment root cause analysis for patient safety incidents at a tertiary care women's and children's hospital: a qualitative feasibility study. Citation Text: Burchell D, MacPhee S, Sinclair D, et al. Using simulation to augment root cause analysis for patient saf…

The influence of organizational culture, climate and commitment on speaking up about medical errors. | PSNet

psnet.ahrq.gov/issue/influence-organizational-culture-climate-and-commitment-speaking-about-medical-errors

December 31, 2018 - Study Emerging Classic The influence of organizational culture, climate and commitment on speaking up about medical errors. Citation Text: Levine KJ, Carmody M, Silk KJ. The influence of organizational culture, climate and commitment on speaking up about medical…

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. | PSNet

psnet.ahrq.gov/issue/implementation-i-pass-handoff-program-diverse-clinical-environments-multicenter-prospective

April 24, 2018 - Study Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. Citation Text: Starmer AJ, Spector ND, O'Toole JK, et al. Implementation of the I‐PASS handoff program in diverse clinical environments: a mu…

Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention. | PSNet

psnet.ahrq.gov/issue/contraindicated-medication-use-dialysis-patients-undergoing-percutaneous-coronary

February 03, 2011 - Study Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention. Citation Text: Tsai TT, Maddox TM, Roe MT, et al. Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention. JAMA. 2009;302(22):2458-64. doi:…

GPT versus resident physicians — a benchmark based on official board scores. | PSNet

psnet.ahrq.gov/issue/gpt-versus-resident-physicians-benchmark-based-official-board-scores

November 03, 2021 - Study GPT versus resident physicians — a benchmark based on official board scores. Citation Text: Katz U, Cohen E, Shachar E, et al. GPT versus resident physicians — a benchmark based on official board scores. NEJM AI. 2024;1(5):5. doi:10.1056/aidbp2300192. Copy Citation Format: …

Making the business case for patient safety. | PSNet

psnet.ahrq.gov/issue/making-business-case-patient-safety

March 04, 2011 - Commentary Making the business case for patient safety. Citation Text: Weeks WB, Bagian JP. Making the business case for patient safety. Jt Comm J Qual Saf. 2003;29(1):51-4, 1. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…

The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs. | PSNet

psnet.ahrq.gov/issue/business-case-quality-economic-analysis-michigan-keystone-patient-safety-program-icus

September 20, 2011 - Study Classic The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs. Citation Text: Waters HR, Korn R, Colantuoni E, et al. The business case for quality: economic analysis of the Michigan Keystone Patient Saf…

TeamGAINS: a tool for structured debriefings for simulation-based team trainings. | PSNet

psnet.ahrq.gov/issue/teamgains-tool-structured-debriefings-simulation-based-team-trainings

October 08, 2016 - Study TeamGAINS: a tool for structured debriefings for simulation-based team trainings. Citation Text: Kolbe M, Weiss M, Grote G, et al. TeamGAINS: a tool for structured debriefings for simulation-based team trainings. BMJ Qual Saf. 2013;22(7):541-53. doi:10.1136/bmjqs-2012-000917. Co…

The PROMISES Project. | PSNet

psnet.ahrq.gov/issue/promises-project

January 30, 2019 - Multi-use Website The PROMISES Project. Citation Text: The PROMISES Project. Brigham and Women's Hospital; Institute for Healthcare Improvement; Massachusetts Coalition for the Prevention of Medical Errors; Coverys; CRICO; Harvard School of Public Health; Harvard Medical School; Health…

Quality and safety in hospital pediatrics during COVID-19: a national qualitative study. | PSNet

psnet.ahrq.gov/issue/quality-and-safety-hospital-pediatrics-during-covid-19-national-qualitative-study

November 17, 2021 - Study Quality and safety in hospital pediatrics during COVID-19: a national qualitative study. Citation Text: De Angulo NR, Penwill N, Pathak PR, et al. Quality and safety in hospital pediatrics during COVID-19: a national qualitative study. Hosp Pediatr. 2022;12(1):e2021006115. doi:10.1…

Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality. | PSNet

psnet.ahrq.gov/issue/effect-multispecialty-faculty-handoff-initiative-safety-culture-and-handoff-quality

March 10, 2019 - Study Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality. Citation Text: Fitzgerald KM, Banerjee TR, Starmer AJ, et al. Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality. Pediatr Qual Saf. 2022;7(2):e539. …

Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review. | PSNet

psnet.ahrq.gov/issue/can-sbar-be-implemented-high-fidelity-and-does-it-improve-communication-between-healthcare

June 22, 2022 - Review Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review. Citation Text: Lo L, Rotteau L, Shojania KG. Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A sys…

Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety. | PSNet

psnet.ahrq.gov/issue/patient-centered-insights-using-health-care-complaints-reveal-hot-spots-and-blind-spots

November 29, 2023 - Study Emerging Classic Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety. Citation Text: Gillespie A, Reader TW. Patient-Centered Insights: Using Health Care Complaints to Reveal Hot Spots and Blind…

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