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  1. Thinking in three's: changing surgical patient safety practices in the complex modern operating room. | PSNet

    psnet.ahrq.gov/issue/thinking-threes-changing-surgical-patient-safety-practices-complex-modern-operating-room
    April 28, 2021 - Commentary Thinking in three's: changing surgical patient safety practices in the complex modern operating room. Citation Text: Gibbs VC. Thinking in three's: changing surgical patient safety practices in the complex modern operating room. World J Gastroenterol. 2012;18(46):6712-9. doi:…

  2. A system-wide initiative to prevent retained vaginal sponges. | PSNet

    psnet.ahrq.gov/issue/system-wide-initiative-prevent-retained-vaginal-sponges
    November 07, 2012 - Commentary A system-wide initiative to prevent retained vaginal sponges. Citation Text: Chagolla BA, Gibbs VC, Keats JP, et al. A system-wide initiative to prevent retained vaginal sponges. MCN Am J Matern Child Nurs. 2011;36(5):312-317. doi:10.1097/NMC.0b013e31822ab204. Copy Citatio…

  3. Fixing patient safety: are we nearly there yet? | PSNet

    psnet.ahrq.gov/issue/fixing-patient-safety-are-we-nearly-there-yet
    April 14, 2021 - Commentary Fixing patient safety: are we nearly there yet? Citation Text: McCulloch P. Fixing patient safety: are we nearly there yet? BMJ Qual Saf. 2024;33(8):539-542. doi:10.1136/bmjqs-2023-016589. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

  4. Why a sociotechnical framework is necessary to address diagnostic error. | PSNet

    psnet.ahrq.gov/issue/why-sociotechnical-framework-necessary-address-diagnostic-error
    September 14, 2022 - Commentary Why a sociotechnical framework is necessary to address diagnostic error. Citation Text: Ladell MM, Yale S, Bordini BJ, et al. Why a sociotechnical framework is necessary to address diagnostic error. BMJ Qual Saf. 2024;33(12):823-828. doi:10.1136/bmjqs-2024-017231. Copy Citat…

  5. Impact of short-notice accreditation assessments on hospitals' patient safety and quality culture--a scoping review. | PSNet

    psnet.ahrq.gov/issue/impact-short-notice-accreditation-assessments-hospitals-patient-safety-and-quality-culture
    January 10, 2024 - Review Impact of short-notice accreditation assessments on hospitals' patient safety and quality culture--a scoping review. Citation Text: Scanlan R, Flenady T, Judd J. Impact of short‐notice accreditation assessments on hospitals' patient safety and quality culture- a scoping review. J …

  6. Organizational culture as a source of high reliability. | PSNet

    psnet.ahrq.gov/issue/organizational-culture-source-high-reliability
    December 03, 2018 - Commentary Classic Organizational culture as a source of high reliability. Citation Text: Weick KE. Organizational Culture as a Source of High Reliability. Calif Manage Rev. 2012;29(2):112-127. doi:10.2307/41165243. Copy Citation Format: DOI Google…

  7. Textbook of Rapid Response Systems: Concept and Implementation. | PSNet

    psnet.ahrq.gov/issue/textbook-rapid-response-systems-concept-and-implementation
    September 30, 2010 - Book/Report Textbook of Rapid Response Systems: Concept and Implementation. Citation Text: Textbook Of Rapid Response Systems: Concept And Implementation. (DeVita MA, ed.). Springer; 2025. ISBN 9783031679513. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…

  8. Obstetric practice guidelines: labor's love lost? | PSNet

    psnet.ahrq.gov/issue/obstetric-practice-guidelines-labors-love-lost
    April 30, 2014 - Commentary Obstetric practice guidelines: labor's love lost? Citation Text: Cohen WR, Friedman EA. Obstetric practice guidelines: labor's love lost? J Matern Fetal Neonatal Med. 2019;32(9):1567-1570. doi:10.1080/14767058.2017.1406474. Copy Citation Format: DOI Google Schola…

  9. Patient safety is not elective: a debate at the NPSF Patient Safety Congress. | PSNet

    psnet.ahrq.gov/issue/patient-safety-not-elective-debate-npsf-patient-safety-congress
    March 18, 2019 - Commentary Patient safety is not elective: a debate at the NPSF Patient Safety Congress. Citation Text: McTiernan P, Wachter R, Meyer GS, et al. Patient safety is not elective: a debate at the NPSF Patient Safety Congress. BMJ Qual Saf. 2015;24(2):162-6. doi:10.1136/bmjqs-2014-003429. …

  10. Ethical duty of health care systems to address interfacility medical error discovery. | PSNet

    psnet.ahrq.gov/issue/ethical-duty-health-care-systems-address-interfacility-medical-error-discovery
    September 11, 2019 - Commentary Ethical duty of health care systems to address interfacility medical error discovery. Citation Text: Antunez AG, Shuman AG, Jagsi R, et al. Ethical Duty of Health Care Systems to Address Interfacility Medical Error Discovery. J Am Coll Surg. 2018;227(5):543-547. doi:10.1016/j.…

  11. Teaching patient safety in global health: lessons from the Duke Global Health Patient Safety Fellowship. | PSNet

    psnet.ahrq.gov/issue/teaching-patient-safety-global-health-lessons-duke-global-health-patient-safety-fellowship
    October 08, 2013 - Commentary Teaching patient safety in global health: lessons from the Duke Global Health Patient Safety Fellowship. Citation Text: Johnston BE, Lou-Meda R, Mendez S, et al. Teaching patient safety in global health: lessons from the Duke Global Health Patient Safety Fellowship. BMJ Glob H…

  12. Bipartisan Consensus: The Public Wants Well-Rested Medical Residents to Help Ensure Safe Patient Care. | PSNet

    psnet.ahrq.gov/issue/bipartisan-consensus-public-wants-well-rested-medical-residents-help-ensure-safe-patient-care
    July 06, 2011 - Book/Report Bipartisan Consensus: The Public Wants Well-Rested Medical Residents to Help Ensure Safe Patient Care. Citation Text: Bipartisan Consensus: The Public Wants Well-Rested Medical Residents to Help Ensure Safe Patient Care. Almashat S, Carome M, Wolfe S, Landrigan CP, Czeisler C…

  13. Predicting the future—big data, machine learning, and clinical medicine. | PSNet

    psnet.ahrq.gov/issue/predicting-future-big-data-machine-learning-and-clinical-medicine
    June 28, 2017 - Commentary Predicting the future—big data, machine learning, and clinical medicine. Citation Text: Obermeyer Z, Emanuel EJ. Predicting the future—big data, machine learning, and clinical medicine. N Engl J Med. 2016;375(13):1216-1219. doi:10.1056/nejmp1606181. Copy Citation Format:…

  14. Fighting against COVID-19: innovative strategies for clinical pharmacists. | PSNet

    psnet.ahrq.gov/issue/fighting-against-covid-19-innovative-strategies-clinical-pharmacists
    March 24, 2019 - Commentary Fighting against COVID-19: innovative strategies for clinical pharmacists. Citation Text: Li H, Zheng S, Liu F, et al. Fighting against COVID-19: innovative strategies for clinical pharmacists. Res Social Adm Pharm. 2020. doi:10.1016/j.sapharm.2020.04.003. Copy Citation …

  15. "Tech-check-tech": a review of the evidence on its safety and benefits. | PSNet

    psnet.ahrq.gov/issue/tech-check-tech-review-evidence-its-safety-and-benefits
    September 23, 2020 - Review "Tech-check-tech": a review of the evidence on its safety and benefits. Citation Text: Adams AJ, Martin SJ, Stolpe SF. "Tech-check-tech": a review of the evidence on its safety and benefits. Am J Health Syst Pharm. 2011;68(19):1824-33. doi:10.2146/ajhp110022. Copy Citation …

  16. Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial. | PSNet

    psnet.ahrq.gov/issue/teaching-teamwork-during-neonatal-resuscitation-program-randomized-trial
    April 08, 2011 - Study Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial. Citation Text: Thomas EJ, Taggart B, Crandell S, et al. Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial. Journal of Perinatology. 2007;27(7). doi:10.1038/sj.jp.7211771…

  17. How to deliver safer and effective patient care: tips for team leaders and educators. | PSNet

    psnet.ahrq.gov/issue/how-deliver-safer-and-effective-patient-care-tips-team-leaders-and-educators
    April 24, 2018 - Commentary How to deliver safer and effective patient care: tips for team leaders and educators. Citation Text: Shah BJ. How to Deliver Safer and Effective Patient Care: Tips for Team Leaders and Educators. Gastroenterology. 2019;156(4):852-855. doi:10.1053/j.gastro.2019.02.017. Copy C…

  18. ACR guidance document on MR safe practices: 2013. | PSNet

    psnet.ahrq.gov/issue/acr-guidance-document-mr-safe-practices-2013
    November 18, 2016 - Commentary ACR guidance document on MR safe practices: 2013. Citation Text: Safety EP on, Kanal E, Barkovich J, et al. ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging. 2013;37(3):501-530. doi:10.1002/jmri.24011. Copy Citation Format: DOI Google Scho…

  19. Recommended responsibilities for management of MR safety. | PSNet

    psnet.ahrq.gov/issue/recommended-responsibilities-management-mr-safety
    April 19, 2013 - Commentary Recommended responsibilities for management of MR safety. Citation Text: Calamante F, Ittermann B, Kanal E, et al. Recommended responsibilities for management of MR safety. J Magn Reson Imaging. 2016;44(5):1067-1069. doi:10.1002/jmri.25282. Copy Citation Format: …

  20. The elusive and illusive quest for diagnostic safety metrics. | PSNet

    psnet.ahrq.gov/issue/elusive-and-illusive-quest-diagnostic-safety-metrics
    October 10, 2018 - Commentary The elusive and illusive quest for diagnostic safety metrics. Citation Text: Schiff G, Ruan EL. The Elusive and Illusive Quest for Diagnostic Safety Metrics. J Gen Intern Med. 2018;33(7):983-985. doi:10.1007/s11606-018-4454-2. Copy Citation Format: DOI Google Sch…
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