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  1. Crib of horrors: one hospital's approach to promoting a culture of safety. | PSNet

    psnet.ahrq.gov/issue/crib-horrors-one-hospitals-approach-promoting-culture-safety
    December 22, 2018 - Commentary Crib of horrors: one hospital's approach to promoting a culture of safety. Citation Text: Korah N, Zavalkoff S, Dubrovsky AS. Crib of Horrors: One Hospital's Approach to Promoting a Culture of Safety. Pediatrics. 2015;136(1):4-5. doi:10.1542/peds.2014-3843. Copy Citation …

  2. Serious adverse drug events reported to the Food and Drug Administration, 1998-2005. | PSNet

    psnet.ahrq.gov/issue/serious-adverse-drug-events-reported-food-and-drug-administration-1998-2005
    June 07, 2016 - Study Serious adverse drug events reported to the Food and Drug Administration, 1998-2005. Citation Text: Moore TJ, Cohen MR, Furberg CD. Serious adverse drug events reported to the Food and Drug Administration, 1998-2005. Arch Intern Med. 2007;167(16):1752-9. Copy Citation Forma…

  3. Briefing and debriefing in the operating room using fighter pilot crew resource management. | PSNet

    psnet.ahrq.gov/issue/briefing-and-debriefing-operating-room-using-fighter-pilot-crew-resource-management
    May 29, 2024 - Study Briefing and debriefing in the operating room using fighter pilot crew resource management. Citation Text: McGreevy JM, Otten TD. Briefing and debriefing in the operating room using fighter pilot crew resource management. J Am Coll Surg. 2007;205(1):169-76. Copy Citation Fo…

  4. Communication in healthcare: a narrative review of the literature and practical recommendations. | PSNet

    psnet.ahrq.gov/issue/communication-healthcare-narrative-review-literature-and-practical-recommendations
    August 04, 2021 - Review Communication in healthcare: a narrative review of the literature and practical recommendations. Citation Text: Vermeir P, Vandijck D, Degroote S, et al. Communication in healthcare: a narrative review of the literature and practical recommendations. Int J Clin Pract. 2015;69(11):…

  5. Patient identification error among prostate needle core biopsy specimens—are we ready for a DNA time-out? | PSNet

    psnet.ahrq.gov/issue/patient-identification-error-among-prostate-needle-core-biopsy-specimens-are-we-ready-dna
    March 12, 2025 - Study Patient identification error among prostate needle core biopsy specimens—are we ready for a DNA time-out? Citation Text: Suba EJ, Pfeifer JD, Raab SS. Patient identification error among prostate needle core biopsy specimens--are we ready for a DNA time-out? J Urol. 2007;178(4 Pt …

  6. Abdominal pain in the emergency department: missed diagnoses. | PSNet

    psnet.ahrq.gov/issue/abdominal-pain-emergency-department-missed-diagnoses
    September 16, 2020 - Commentary Abdominal pain in the emergency department: missed diagnoses. Citation Text: Halsey-Nichols M, McCoin N. Abdominal pain in the emergency department: missed diagnoses. Emerg Med Clin North Am. 2021;39(4):703-717. doi:10.1016/j.emc.2021.07.005. Copy Citation Format: …

  7. Discontinuation of antihyperglycemic therapy after acute myocardial infarction: medical necessity or medical error? | PSNet

    psnet.ahrq.gov/issue/discontinuation-antihyperglycemic-therapy-after-acute-myocardial-infarction-medical-necessity
    February 28, 2011 - Study Discontinuation of antihyperglycemic therapy after acute myocardial infarction: medical necessity or medical error? Citation Text: Lovig KO, Horwitz LI, Lipska K, et al. Discontinuation of antihyperglycemic therapy after acute myocardial infarction: medical necessity or medical e…

  8. Lessons from "unexpected increased mortality after implementation of a commercially sold computerized physician order entry system." | PSNet

    psnet.ahrq.gov/issue/lessons-unexpected-increased-mortality-after-implementation-commercially-sold-computerized
    April 29, 2018 - Commentary Lessons from "unexpected increased mortality after implementation of a commercially sold computerized physician order entry system." Citation Text: Sittig DF, Ash JS, Zhang J, et al. Lessons from "Unexpected increased mortality after implementation of a commercially sold com…

  9. Frequent diagnostic errors in cardiac PET/CT due to misregistration of CT attenuation and emission PET images: a definitive analysis of causes, consequences, and corrections. | PSNet

    psnet.ahrq.gov/issue/frequent-diagnostic-errors-cardiac-petct-due-misregistration-ct-attenuation-and-emission-pet
    December 22, 2018 - Study Frequent diagnostic errors in cardiac PET/CT due to misregistration of CT attenuation and emission PET images: a definitive analysis of causes, consequences, and corrections. Citation Text: Gould L, Pan T, Loghin C, et al. Frequent diagnostic errors in cardiac PET/CT due to misre…

  10. A system safety approach to assessing risks in the sepsis treatment process. | PSNet

    psnet.ahrq.gov/issue/system-safety-approach-assessing-risks-sepsis-treatment-process
    February 03, 2021 - Study A system safety approach to assessing risks in the sepsis treatment process. Citation Text: Kaya GK. A system safety approach to assessing risks in the sepsis treatment process. Appl Ergon. 2021;94:103408. doi:10.1016/j.apergo.2021.103408. Copy Citation Format: DOI Go…

  11. Omitted and unjustified medications in the discharge summary. | PSNet

    psnet.ahrq.gov/issue/omitted-and-unjustified-medications-discharge-summary
    May 18, 2022 - Study Omitted and unjustified medications in the discharge summary. Citation Text: Perren A, Previsdomini M, Cerutti B, et al. Omitted and unjustified medications in the discharge summary. Qual Saf Health Care. 2009;18(3):205-8. doi:10.1136/qshc.2007.024588. Copy Citation Format: …

  12. Hospital costs associated with adverse events in gynecological oncology. | PSNet

    psnet.ahrq.gov/issue/hospital-costs-associated-adverse-events-gynecological-oncology
    March 09, 2022 - Study Hospital costs associated with adverse events in gynecological oncology. Citation Text: Kondalsamy-Chennakesavan S, Gordon LG, Sanday K, et al. Hospital costs associated with adverse events in gynecological oncology. Gynecol Oncol. 2011;121(1):70-5. doi:10.1016/j.ygyno.2010.11.03…

  13. Nurses' response to parents' 'speaking-up' efforts to ensure their hospitalized child's safety: an attribution theory perspective. | PSNet

    psnet.ahrq.gov/issue/nurses-response-parents-speaking-efforts-ensure-their-hospitalized-childs-safety-attribution
    May 13, 2020 - Study Nurses' response to parents' 'speaking-up' efforts to ensure their hospitalized child's safety: an attribution theory perspective. Citation Text: Bsharat S, Drach-Zahavy A. Nurses' response to parents' 'speaking-up' efforts to ensure their hospitalized child's safety: an attributio…

  14. Computer physician order entry: benefits, costs, and issues. | PSNet

    psnet.ahrq.gov/issue/computer-physician-order-entry-benefits-costs-and-issues
    May 27, 2011 - Study Computer physician order entry: benefits, costs, and issues. Citation Text: Kuperman GJ, Gibson RF. Computer physician order entry: benefits, costs, and issues. Ann Intern Med. 2003;139(1):31-9. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNo…

  15. Clinical information transfer and medication reconciliation in patients transferred from the pediatric intensive care unit. | PSNet

    psnet.ahrq.gov/issue/clinical-information-transfer-and-medication-reconciliation-patients-transferred-pediatric
    September 28, 2010 - Study Clinical information transfer and medication reconciliation in patients transferred from the pediatric intensive care unit. Citation Text: Grant MJC, Larsen GY. Clinical Information Transfer and Medication Reconciliation in Patients Transferred from the Pediatric Intensive Care U…

  16. Maximizing student potential: lessons for pharmacy programs from the patient safety movement. | PSNet

    psnet.ahrq.gov/issue/maximizing-student-potential-lessons-pharmacy-programs-patient-safety-movement
    October 23, 2024 - Commentary Maximizing student potential: lessons for pharmacy programs from the patient safety movement. Citation Text: Abebe E, Bao A, Kokkinias P, et al. Maximizing student potential: lessons for pharmacy programs from the patient safety movement. Explor Res Clin Soc Pharm. 2023;9:1002…

  17. A really stupid mistake: it does feel like a cop out to blame my error on human frailty, but I'm afraid that's exactly what it was. | PSNet

    psnet.ahrq.gov/issue/really-stupid-mistake-it-does-feel-cop-out-blame-my-error-human-frailty-im-afraid-thats
    August 16, 2023 - Commentary A really stupid mistake: it does feel like a cop out to blame my error on human frailty, but I'm afraid that's exactly what it was. Citation Text: Maskell G. A really stupid mistake: it does feel like a cop out to blame my error on human frailty, but I'm afraid that's exactly …

  18. Read-back improves information transfer in simulated clinical crises. | PSNet

    psnet.ahrq.gov/issue/read-back-improves-information-transfer-simulated-clinical-crises
    March 12, 2017 - Study Read-back improves information transfer in simulated clinical crises. Citation Text: Boyd M, Cumin D, Lombard B, et al. Read-back improves information transfer in simulated clinical crises. BMJ Qual Saf. 2014;23(12):989-93. doi:10.1136/bmjqs-2014-003096. Copy Citation Format:…

  19. Impact and culture change after the implementation of a preprocedural checklist in an interventional radiology department. | PSNet

    psnet.ahrq.gov/issue/impact-and-culture-change-after-implementation-preprocedural-checklist-interventional
    May 05, 2021 - Study Impact and culture change after the implementation of a preprocedural checklist in an interventional radiology department. Citation Text: Wong SSN, Cleverly S, Tan KT, et al. Impact and Culture Change After the Implementation of a Preprocedural Checklist in an Interventional Radiol…

  20. Antibiotic timing and errors in diagnosing pneumonia. | PSNet

    psnet.ahrq.gov/issue/antibiotic-timing-and-errors-diagnosing-pneumonia
    March 20, 2024 - Study Antibiotic timing and errors in diagnosing pneumonia. Citation Text: Welker JA, Huston M, McCue JD. Antibiotic timing and errors in diagnosing pneumonia. Arch Intern Med. 2008;168(4):351-6. doi:10.1001/archinternmed.2007.84. Copy Citation Format: DOI Google Scholar …
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