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  1. Oversedation of a patient with obstructive sleep apnea prior to imaging. | PSNet

    psnet.ahrq.gov/issue/oversedation-patient-obstructive-sleep-apnea-prior-imaging
    September 02, 2020 - Commentary Oversedation of a patient with obstructive sleep apnea prior to imaging. Citation Text: Blay E, Barnard C, Bilimoria KY. Oversedation of a Patient With Obstructive Sleep Apnea Prior to Imaging. JAMA. 2018;319(5):495-496. doi:10.1001/jama.2017.22004. Copy Citation Format:…

  2. IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices. | PSNet

    psnet.ahrq.gov/issue/iv-push-gap-analysis-tool-gat-helps-uncover-national-priorities-safe-injection-practices
    August 14, 2019 - Newspaper/Magazine Article IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices. Citation Text: IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices. ISMP Medication Safety Alert! Acute Care Edition. Augu…

  3. Current issues in patient safety in surgery: a review. | PSNet

    psnet.ahrq.gov/issue/current-issues-patient-safety-surgery-review
    July 26, 2017 - Review Current issues in patient safety in surgery: a review. Citation Text: Kim FJ, da Silva RD, Gustafson D, et al. Current issues in patient safety in surgery: a review. Patient Saf Surg. 2015;9:26. doi:10.1186/s13037-015-0067-4. Copy Citation Format: DOI Google Scholar …

  4. Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy. | PSNet

    psnet.ahrq.gov/issue/improving-patient-safety-through-informed-consent-patients-limited-health-literacy
    April 28, 2021 - Book/Report Classic Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy. Citation Text: Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy. Wu HW, Nishimi RY, Page-Lopez CM, et …

  5. Achieving a climate for patient safety by focusing on relationships. | PSNet

    psnet.ahrq.gov/issue/achieving-climate-patient-safety-focusing-relationships
    December 19, 2017 - Study Achieving a climate for patient safety by focusing on relationships. Citation Text: Manojlovich M, Kerr M, Davies B, et al. Achieving a climate for patient safety by focusing on relationships. Int J Qual Health Care. 2014;26(6):579-84. doi:10.1093/intqhc/mzu068. Copy Citation …

  6. Have you M.E.T. the future of better patient safety? | PSNet

    psnet.ahrq.gov/issue/have-you-met-future-better-patient-safety
    November 13, 2024 - Newspaper/Magazine Article Have you M.E.T. the future of better patient safety? Citation Text: Larson L. Have you M.E.T. the future of better patient safety? Trustee : the journal for hospital governing boards. 2005;58(8):6-10, 1. Copy Citation Format: Google Scholar PubMed…

  7. Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations. | PSNet

    psnet.ahrq.gov/issue/any-new-process-poses-risk-errors-learning-4-months-coronavirus-disease-2019-covid-19
    June 10, 2018 - Newspaper/Magazine Article Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations. Citation Text: Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations. ISMP Medicat…

  8. America's Hospitals: Improving Quality and Safety—The Joint Commission's Annual Report 2016. | PSNet

    psnet.ahrq.gov/issue/americas-hospitals-improving-quality-and-safety-joint-commissions-annual-report-2016
    November 10, 2016 - Book/Report America's Hospitals: Improving Quality and Safety—The Joint Commission's Annual Report 2016. Citation Text: America's Hospitals: Improving Quality and Safety—The Joint Commission's Annual Report 2016. Oakbrook Terrace, IL: The Joint Commission; November 2016. Copy Citation …

  9. The association between organizational culture and the ability to benefit from "just culture" training. | PSNet

    psnet.ahrq.gov/issue/association-between-organizational-culture-and-ability-benefit-just-culture-training
    August 04, 2021 - Study The association between organizational culture and the ability to benefit from "just culture" training. Citation Text: David DS. The Association Between Organizational Culture and the Ability to Benefit From "Just Culture" Training. J Patient Saf. 2019;15(1):e3-e7. doi:10.1097/PTS.…

  10. Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. | PSNet

    psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone-overdose
    June 03, 2020 - Newspaper/Magazine Article Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. Citation Text: Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. ISMP Medication Safety Alert! Acute care edition. May 7…

  11. Understanding middle managers' influence in implementing patient safety culture. | PSNet

    psnet.ahrq.gov/issue/understanding-middle-managers-influence-implementing-patient-safety-culture
    March 24, 2012 - Commentary Understanding middle managers' influence in implementing patient safety culture. Citation Text: Gutberg J, Berta W. Understanding middle managers' influence in implementing patient safety culture. BMC Health Serv Res. 2017;17(1):582. doi:10.1186/s12913-017-2533-4. Copy Citat…

  12. Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital. | PSNet

    psnet.ahrq.gov/issue/patient-safety-developing-countries-retrospective-estimation-scale-and-nature-harm-patients
    March 23, 2011 - Study Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital. Citation Text: Wilson R, Michel P, Olsen S, et al. Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hos…

  13. FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing. | PSNet

    psnet.ahrq.gov/issue/fda-safety-communication-flexible-bronchoscopes-and-updated-recommendations-reprocessing
    March 11, 2015 - Press Release/Announcement FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing. Citation Text: FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing. Silver Springs, MD: US Food and Drug Administration: Jun…

  14. Can we import improvements from industry to healthcare? | PSNet

    psnet.ahrq.gov/issue/can-we-import-improvements-industry-healthcare
    October 30, 2010 - Commentary Can we import improvements from industry to healthcare? Citation Text: Macrae C, Stewart K. Can we import improvements from industry to healthcare? BMJ. 2019;364:l1039. doi:10.1136/bmj.l1039. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML E…

  15. Why even good physicians do not wash their hands. | PSNet

    psnet.ahrq.gov/issue/why-even-good-physicians-do-not-wash-their-hands
    September 21, 2022 - Commentary Why even good physicians do not wash their hands. Citation Text: Redelmeier DA, Shafir E. Why even good physicians do not wash their hands. BMJ Qual Saf. 2015;24(12):744-7. doi:10.1136/bmjqs-2015-004319. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndN…

  16. Waiting for urgent procedures on the weekend among emergently hospitalized patients. | PSNet

    psnet.ahrq.gov/issue/waiting-urgent-procedures-weekend-among-emergently-hospitalized-patients
    September 04, 2019 - Study Waiting for urgent procedures on the weekend among emergently hospitalized patients. Citation Text: Bell CM, Redelmeier DA. Waiting for urgent procedures on the weekend among emergently hospitalized patients. Am J Med. 2004;117(3):175-81. Copy Citation Format: Googl…

  17. Recommendations to ensure safety of AI in real-world clinical care. | PSNet

    psnet.ahrq.gov/issue/recommendations-ensure-safety-ai-real-world-clinical-care
    December 06, 2023 - Commentary Recommendations to ensure safety of AI in real-world clinical care. Citation Text: Sittig DF, Singh H. Recommendations to ensure safety of AI in real-world clinical care. JAMA. 2025;333(6):457-458. doi:10.1001/jama.2024.24598. Copy Citation Format: DOI Google Sch…

  18. Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2007. | PSNet

    psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-safety-2007
    April 24, 2007 - Book/Report Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2007. Citation Text: Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2007. Oakbrook Terrace, IL: Joint Commission; 2007. Copy Citat…

  19. Simulation techniques for teaching time-outs: a controlled trial. | PSNet

    psnet.ahrq.gov/issue/simulation-techniques-teaching-time-outs-controlled-trial
    June 22, 2016 - Study Simulation techniques for teaching time-outs: a controlled trial. Citation Text: Simulation techniques for teaching time-outs: a controlled trial. Paull DE, Williams L, Sine DM. Patient Saf Qual Healthc. March/April 2016;13:28-37. Copy Citation Save Save to …

  20. Imitating incidents: how simulation can improve safety investigation and learning from adverse events. | PSNet

    psnet.ahrq.gov/issue/imitating-incidents-how-simulation-can-improve-safety-investigation-and-learning-adverse
    February 28, 2024 - Commentary Imitating incidents: how simulation can improve safety investigation and learning from adverse events. Citation Text: Macrae C. Imitating Incidents: How Simulation Can Improve Safety Investigation and Learning From Adverse Events. Simul Healthc. 2018;13(4):227-232. doi:10.1097…
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