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  1. Submit Case | PSNet

    psnet.ahrq.gov/submit-case-landing
    March 25, 2025 - Breadcrumb Home Training and Education WebM&M: Case Studies WebM&M Case Submission PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential …

  2. Creating an infrastructure for safety event reporting and analysis in a multicenter pediatric emergency department network. | PSNet

    psnet.ahrq.gov/issue/creating-infrastructure-safety-event-reporting-and-analysis-multicenter-pediatric-emergency
    October 08, 2013 - Study Creating an infrastructure for safety event reporting and analysis in a multicenter pediatric emergency department network. Citation Text: Chamberlain JM, Shaw KN, Lillis KA, et al. Creating an infrastructure for safety event reporting and analysis in a multicenter pediatric emer…

  3. An international review of patient safety measures in radiotherapy practice. | PSNet

    psnet.ahrq.gov/issue/international-review-patient-safety-measures-radiotherapy-practice
    May 22, 2019 - Review An international review of patient safety measures in radiotherapy practice. Citation Text: Shafiq J, Barton M, Noble DJ, et al. An international review of patient safety measures in radiotherapy practice. Radiother Oncol. 2009;92(1):15-21. doi:10.1016/j.radonc.2009.03.007. Co…

  4. Radiology research in quality and safety: current trends and future needs. | PSNet

    psnet.ahrq.gov/issue/radiology-research-quality-and-safety-current-trends-and-future-needs
    November 16, 2022 - Review Radiology research in quality and safety: current trends and future needs. Citation Text: Zygmont ME, Itri JN, Rosenkrantz AB, et al. Radiology Research in Quality and Safety: Current Trends and Future Needs. Acad Radiol. 2017;24(3):263-272. doi:10.1016/j.acra.2016.07.021. Copy …

  5. Addressing safety concerns about U-500 insulin in a hospital setting. | PSNet

    psnet.ahrq.gov/issue/addressing-safety-concerns-about-u-500-insulin-hospital-setting
    March 15, 2017 - Commentary Addressing safety concerns about U-500 insulin in a hospital setting. Citation Text: Samaan KH, Dahlke M, Stover J. Addressing safety concerns about U-500 insulin in a hospital setting. Am J Health Syst Pharm. 2011;68(1):63-8. doi:10.2146/ajhp100224. Copy Citation Form…

  6. What makes hospitalized patients more vulnerable and increases their risk of experiencing an adverse event? | PSNet

    psnet.ahrq.gov/issue/what-makes-hospitalized-patients-more-vulnerable-and-increases-their-risk-experiencing
    March 23, 2011 - Study What makes hospitalized patients more vulnerable and increases their risk of experiencing an adverse event? Citation Text: Aranaz-Andrés JM, Limón R, Mira JJ, et al. What makes hospitalized patients more vulnerable and increases their risk of experiencing an adverse event? Int J Qu…

  7. Learning from mistakes and near mistakes: using root cause analysis as a risk management tool. | PSNet

    psnet.ahrq.gov/issue/learning-mistakes-and-near-mistakes-using-root-cause-analysis-risk-management-tool
    June 19, 2024 - Commentary Learning from mistakes and near mistakes: using root cause analysis as a risk management tool. Citation Text: Cerniglia-Lowensen J. Learning From Mistakes and Near Mistakes: Using Root Cause Analysis as a Risk Management Tool. J Radiol Nurs. 2015;34(1). doi:10.1016/j.jradnu.20…

  8. An overview of the use and implementation of checklists in surgical specialities - a systematic review. | PSNet

    psnet.ahrq.gov/issue/overview-use-and-implementation-checklists-surgical-specialities-systematic-review
    July 31, 2013 - Review An overview of the use and implementation of checklists in surgical specialities - a systematic review. Citation Text: Patel J, Ahmed K, Guru KA, et al. An overview of the use and implementation of checklists in surgical specialities - a systematic review. Int J Surg. 2014;12(12):…

  9. Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program. | PSNet

    psnet.ahrq.gov/issue/effect-systems-intervention-quality-and-safety-patient-handoffs-internal-medicine-residency
    May 08, 2017 - Study Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program. Citation Text: Graham KL, Marcantonio ER, Huang GC, et al. Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicin…

  10. 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…

  11. Rework and workarounds in nurse medication administration process: implications for work processes and patient safety. | PSNet

    psnet.ahrq.gov/issue/rework-and-workarounds-nurse-medication-administration-process-implications-work-processes
    July 31, 2008 - Study Rework and workarounds in nurse medication administration process: implications for work processes and patient safety. Citation Text: Halbesleben JRB, Savage GT, Wakefield DS, et al. Rework and workarounds in nurse medication administration process: implications for work processes…

  12. Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA. | PSNet

    psnet.ahrq.gov/issue/pathology-oversight-failures-veterans-health-care-system-ozarks-fayetteville-arkansas-va
    July 14, 2021 - Book/Report Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA. Citation Text: Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA. Office of Inspector General. June 2, 202…

  13. 5-Red-Light-Green-Light (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/5-red-light-green-light.docx
    June 01, 2023 - AHRQ Safety Program for Improving Surgical Care and Recovery Red Light, Green Light: An Overview of Common Implementation Barriers and Facilitators Purpose of this tool: To help team leaders identify barriers to and facilitators of implementing Improving Surgical Care and Recovery (ISCR), an enhanced recovery program…

  14. Changes to supervision in community pharmacy: pharmacist and pharmacy support staff views. | PSNet

    psnet.ahrq.gov/issue/changes-supervision-community-pharmacy-pharmacist-and-pharmacy-support-staff-views
    June 17, 2020 - Study Changes to supervision in community pharmacy: pharmacist and pharmacy support staff views. Citation Text: Bradley F, Schafheutle EI, Willis SC, et al. Changes to supervision in community pharmacy: pharmacist and pharmacy support staff views. Health Soc Care Community. 2013;21(6):…

  15. Detection, classification, and correction of defective chemotherapy orders through nursing and pharmacy oversight. | PSNet

    psnet.ahrq.gov/issue/detection-classification-and-correction-defective-chemotherapy-orders-through-nursing-and
    May 27, 2011 - Study Detection, classification, and correction of defective chemotherapy orders through nursing and pharmacy oversight. Citation Text: Mertens WC, Brown DE, Parisi R, et al. Detection, Classification, and Correction of Defective Chemotherapy Orders Through Nursing and Pharmacy Oversig…

  16. Antiretroviral medication prescribing errors are common with hospitalization of HIV-infected patients. | PSNet

    psnet.ahrq.gov/issue/antiretroviral-medication-prescribing-errors-are-common-hospitalization-hiv-infected-patients
    September 08, 2016 - Study Antiretroviral medication prescribing errors are common with hospitalization of HIV-infected patients. Citation Text: Commers T, Swindells S, Sayles H, et al. Antiretroviral medication prescribing errors are common with hospitalization of HIV-infected patients. J Antimicrob Chemo…

  17. Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions. | PSNet

    psnet.ahrq.gov/issue/utilizing-information-technology-mitigate-handoff-risks-caused-resident-work-hour
    March 17, 2010 - Commentary Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions. Citation Text: Bernstein J, MacCourt DC, Jacob DM, et al. Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions. Clin …

  18. A theoretical framework and competency-based approach to improving handoffs. | PSNet

    psnet.ahrq.gov/issue/theoretical-framework-and-competency-based-approach-improving-handoffs
    March 28, 2011 - Commentary A theoretical framework and competency-based approach to improving handoffs. Citation Text: Arora VM, Johnson JK, Meltzer DO, et al. A theoretical framework and competency-based approach to improving handoffs. Qual Saf Health Care. 2008;17(1):11-4. doi:10.1136/qshc.2006.0189…

  19. Exploring and evaluating patient safety culture in a community-based primary care setting. | PSNet

    psnet.ahrq.gov/issue/exploring-and-evaluating-patient-safety-culture-community-based-primary-care-setting
    March 19, 2018 - Study Exploring and evaluating patient safety culture in a community-based primary care setting. Citation Text: Desmedt M, Bergs J, Willaert B, et al. Exploring and Evaluating Patient Safety Culture in a Community-Based Primary Care Setting. J Patient Saf. 2021;17(8):e1216-e1222. doi:10.…

  20. In situ simulated cardiac arrest exercises to detect system vulnerabilities. | PSNet

    psnet.ahrq.gov/issue/situ-simulated-cardiac-arrest-exercises-detect-system-vulnerabilities
    June 27, 2012 - Study In situ simulated cardiac arrest exercises to detect system vulnerabilities. Citation Text: Barbeito A, Bonifacio AS, Holtschneider M, et al. In situ simulated cardiac arrest exercises to detect system vulnerabilities. Simul Healthc. 2015;10(3):154-62. doi:10.1097/SIH.0000000000000…
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