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psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
March 25, 2020 - Evaluation of Anesthesiology Residents' Supervision Skills: A Tool to Assess Transition Towards Independent
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psnet.ahrq.gov/node/39018/psn-pdf
October 14, 2009 - When the doctor is distressed.
October 14, 2009
Chen PW.
https://psnet.ahrq.gov/issue/when-doctor-distressed
This column discusses how life stresses affect the reliability and safety of care provided by over-extended
clinicians in light of a recent study on the topic.
https://psnet.ahrq.gov/issue/when-doctor-dist…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-measure-implementation.pdf
August 01, 2025 - ■ A post-hospital discharge project examined adverse events occurring when nursing home residents … proportions of White residents showed better reporting for falls but
worse for pressure ulcers. … Eventually the research team rolled out the intervention
to residents and advanced practice providers … residents lacked health insurance, including 11.6% of persons with disabilities. … Researchers determined that
adverse events occurred in 37.3% of discharges of LTC residents from the
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psnet.ahrq.gov/issue/ahrq-nursing-home-survey-patient-safety-culture-2019-user-comparative-database-report
April 17, 2019 - Book/Report
AHRQ Nursing Home Survey on Patient Safety Culture: 2019 User Comparative Database Report.
Citation Text:
AHRQ Nursing Home Survey on Patient Safety Culture: 2019 User Comparative Database Report. Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Resea…
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psnet.ahrq.gov/issue/development-research-agenda-identify-evidence-based-strategies-improve-physician-wellness-and
June 01, 2022 - Commentary
Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout.
Citation Text:
Dyrbye LN, Trockel M, Frank E, et al. Development of a Research Agenda to Identify Evidence-Based Strategies to Improve Physician Wellness an…
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psnet.ahrq.gov/issue/improving-situation-awareness-reduce-unrecognized-clinical-deterioration-and-serious-safety
December 02, 2014 - Study
Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.
Citation Text:
Brady PW, Muething S, Kotagal U, et al. Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. Pediatrics. 2013;131(…
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psnet.ahrq.gov/issue/relationship-between-preventability-death-after-coronary-artery-bypass-graft-surgery-and-all
September 23, 2020 - Study
Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates.
Citation Text:
Guru V, Tu J, Etchells E, et al. Relationship between preventability of death after coronary artery bypass graft surgery and all-cau…
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psnet.ahrq.gov/issue/association-opioid-prescribing-opioid-consumption-after-surgery-michigan
December 02, 2020 - Study
Classic
Association of opioid prescribing with opioid consumption after surgery in Michigan.
Citation Text:
Howard R, Fry B, Gunaseelan V, et al. Association of Opioid Prescribing With Opioid Consumption After Surgery in Michigan. JAMA Surg. 2019;154(1):e1…
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psnet.ahrq.gov/issue/adverse-events-during-intrahospital-transport-critically-ill-children-systematic-review
October 14, 2020 - Review
Adverse events during intrahospital transport of critically ill children: a systematic review.
Citation Text:
Haydar B, Baetzel A, Elliott A, et al. Adverse Events During Intrahospital Transport of Critically Ill Children: A Systematic Review. Anesth Analg. 2020;131(4):1135-1145. …
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psnet.ahrq.gov/issue/measurement-and-monitoring-safety-framework-qualitative-study-implementation-through-canadian
January 24, 2024 - Study
Measurement and Monitoring of Safety Framework: a qualitative study of implementation through a Canadian learning collaborative.
Citation Text:
Goldman J, Rotteau L, Flintoft V, et al. Measurement and Monitoring of Safety Framework: a qualitative study of implementation through a C…
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psnet.ahrq.gov/issue/american-college-surgeons-closed-claims-study-new-insights-improving-care
March 02, 2011 - Study
The American College of Surgeons' closed claims study: new insights for improving care.
Citation Text:
Griffen FD, Stephens LS, Alexander JB, et al. The American College of Surgeons’ Closed Claims Study: New Insights for Improving Care. J Am Coll Surg. 2007;204(4). doi:10.1016/j.…
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psnet.ahrq.gov/issue/fix-and-forget-or-fix-and-report-qualitative-study-tensions-front-line-incident-reporting
May 18, 2016 - Study
Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting.
Citation Text:
Hewitt TA, Chreim S. Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting. BMJ Qual Saf. 2015;24(5):303-10.…
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psnet.ahrq.gov/issue/racial-disparities-pain-management-children-appendicitis-emergency-departments
April 22, 2020 - Study
Racial disparities in pain management of children with appendicitis in emergency departments.
Citation Text:
Goyal MK, Kuppermann N, Cleary SD, et al. Racial disparities in pain management of children with appendicitis in emergency departments. JAMA Pediatr. 2015;169(11):996-1002. …
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psnet.ahrq.gov/issue/interventions-engage-patients-and-families-patient-safety-systematic-review
March 04, 2020 - Review
Interventions to engage patients and families in patient safety: a systematic review.
Citation Text:
Lee M, Lee N-J, Seo H-J, et al. Interventions to Engage Patients and Families in Patient Safety: A Systematic Review. West J Nurs Res. 2021;43(10):972-983. doi:10.1177/01939459209…
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psnet.ahrq.gov/issue/nurse-burnout-syndrome-and-work-environment-impact-patient-safety-grade
August 04, 2021 - Study
Nurse burnout syndrome and work environment impact patient safety grade.
Citation Text:
Montgomery AP, Patrician PA, Azuero A. Nurse burnout syndrome and work environment impact patient safety grade. J Nurs Care Qual. 2022;37(1):87-93. doi:10.1097/ncq.0000000000000574.
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psnet.ahrq.gov/issue/association-between-professional-burnout-and-engagement-patient-safety-culture-and-outcomes
October 28, 2020 - Review
The association between professional burnout and engagement with patient safety culture and outcomes: a systematic review.
Citation Text:
Mossburg SE, Himmelfarb CD. The Association Between Professional Burnout and Engagement With Patient Safety Culture and Outcomes: A Systematic …
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psnet.ahrq.gov/issue/incidence-multiple-sclerosis-misdiagnosis-referrals-two-academic-centers
April 24, 2018 - Study
Emerging Classic
Incidence of multiple sclerosis misdiagnosis in referrals to two academic centers.
Citation Text:
Kaisey M, Solomon AJ, Luu M, et al. Incidence of multiple sclerosis misdiagnosis in referrals to two academic centers. Mult Scler Relat Disor…
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psnet.ahrq.gov/issue/safety-cases-digital-health-innovations-can-they-work
April 13, 2022 - Commentary
Safety cases for digital health innovations: can they work?
Citation Text:
Sujan M, Habli I. Safety cases for digital health innovations: can they work? BMJ Qual Saf. 2021;30(12):1047-1050. doi:10.1136/bmjqs-2021-012983.
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Format:
DOI Google Scholar B…
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psnet.ahrq.gov/issue/bariatric-surgery-operating-room-teams-stayed-fixed-during-day-multicenter-study-analyzing
December 21, 2014 - Study
Bariatric surgery with operating room teams that stayed fixed during the day: a multicenter study analyzing the effects on patient outcomes, teamwork and safety climate, and procedure duration.
Citation Text:
Stepaniak PS, Heij C, Buise MP, et al. Bariatric surgery with operating r…
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psnet.ahrq.gov/issue/comfort-uncertainty-reframing-our-conceptions-how-clinicians-navigate-complex-clinical
February 06, 2013 - Review
Emerging Classic
Comfort with uncertainty: reframing our conceptions of how clinicians navigate complex clinical situations.
Citation Text:
Ilgen JS, Eva KW, de Bruin A, et al. Comfort with uncertainty: reframing our conceptions of how clinicians navigate…