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  1. The problem with 'never events'. | PSNet

    psnet.ahrq.gov/issue/problem-never-events
    July 12, 2023 - Commentary The problem with 'never events'. Citation Text: Zaslow J, Fortier J, Garber G. The problem with ‘never events’. BMJ Qual Saf. 2024;33(9):613-616. doi:10.1136/bmjqs-2023-016981. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

  2. Safety-I, Safety-II and resilience engineering. | PSNet

    psnet.ahrq.gov/issue/safety-i-safety-ii-and-resilience-engineering
    December 16, 2015 - Commentary Safety-I, Safety-II and resilience engineering. Citation Text: Patterson M, Deutsch ES. Safety-I, Safety-II and resilience engineering. Curr Probl Pediatr Adolesc Health Care. 2015;45(12):382-389. doi:10.1016/j.cppeds.2015.10.001. Copy Citation Format: DOI Google…

  3. Rapid response systems as a patient safety strategy: a systematic review. | PSNet

    psnet.ahrq.gov/issue/rapid-response-systems-patient-safety-strategy-systematic-review
    March 20, 2013 - Review Rapid response systems as a patient safety strategy: a systematic review. Citation Text: Winters BD, Weaver SJ, Pfoh ER, et al. Rapid-response systems as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):417-25. doi:10.7326/0003-4819-158-5-201303051…

  4. Nurse staffing levels and patient-reported missed nursing care. | PSNet

    psnet.ahrq.gov/issue/nurse-staffing-levels-and-patient-reported-missed-nursing-care
    September 27, 2017 - Study Nurse staffing levels and patient-reported missed nursing care. Citation Text: Dabney BW, Kalisch BJ. Nurse Staffing Levels and Patient-Reported Missed Nursing Care. J Nurs Care Qual. 2015;30(4):306-12. doi:10.1097/NCQ.0000000000000123. Copy Citation Format: DOI Googl…

  5. Hospital performance trends on national quality measures and the association with Joint Commission accreditation. | PSNet

    psnet.ahrq.gov/issue/hospital-performance-trends-national-quality-measures-and-association-joint-commission
    September 20, 2011 - Study Hospital performance trends on national quality measures and the association with Joint Commission accreditation. Citation Text: Schmaltz SP, Williams SC, Chassin MR, et al. Hospital performance trends on national quality measures and the association with joint commission accre…

  6. Diagnosing overdiagnosis: conceptual challenges and suggested solutions. | PSNet

    psnet.ahrq.gov/issue/diagnosing-overdiagnosis-conceptual-challenges-and-suggested-solutions
    September 20, 2023 - Commentary Diagnosing overdiagnosis: conceptual challenges and suggested solutions. Citation Text: Hofmann B. Diagnosing overdiagnosis: conceptual challenges and suggested solutions. Eur J Epidemiol. 2014;29(9):599-604. doi:10.1007/s10654-014-9920-5. Copy Citation Format: D…

  7. Network of Patient Safety Databases Chartbook, 2019 | PSNet

    psnet.ahrq.gov/issue/network-patient-safety-databases-chartbook-2019
    October 23, 2019 - Book/Report Network of Patient Safety Databases Chartbook, 2019 Citation Text: Network of Patient Safety Databases Chartbook, 2019 Rockville, MD: Agency for Healthcare Research and Quality; December 2019. AHRQ Pub No 20-0023. Copy Citation Save Save to your librar…

  8. AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Engaging Patients and Families. | PSNet

    psnet.ahrq.gov/issue/ahrq-funded-patient-safety-project-highlights-improving-healthcare-safety-engaging-patients
    March 22, 2024 - Book/Report AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Engaging Patients and Families. Citation Text: AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Engaging Patients and Families. Rockville, MD: Agency for Healthcare Rese…

  9. Safety considerations in learning new procedures: a survey of surgeons. | PSNet

    psnet.ahrq.gov/issue/safety-considerations-learning-new-procedures-survey-surgeons
    January 23, 2017 - Study Safety considerations in learning new procedures: a survey of surgeons. Citation Text: Jaffe TA, Hasday SJ, Knol M, et al. Safety considerations in learning new procedures: a survey of surgeons. J Surg Res. 2017;218:361-366. doi:10.1016/j.jss.2017.06.058. Copy Citation Format…

  10. The ongoing quality improvement journey: next stop, high reliability. | PSNet

    psnet.ahrq.gov/issue/ongoing-quality-improvement-journey-next-stop-high-reliability
    January 23, 2012 - Commentary The ongoing quality improvement journey: next stop, high reliability. Citation Text: Chassin MR, Loeb JM. The ongoing quality improvement journey: next stop, high reliability. Health Aff (Millwood). 2011;30(4):559-68. doi:10.1377/hlthaff.2011.0076. Copy Citation Format…

  11. Intrathecal chemotherapy: potential for medication error. | PSNet

    psnet.ahrq.gov/issue/intrathecal-chemotherapy-potential-medication-error
    February 23, 2015 - Review Intrathecal chemotherapy: potential for medication error. Citation Text: Gilbar PJ. Intrathecal chemotherapy: potential for medication error. Cancer Nurs. 2014;37(4):299-309. doi:10.1097/NCC.0000000000000108. Copy Citation Format: DOI Google Scholar PubMed BibTeX End…

  12. The effect of drug concentration expression on epinephrine dosing errors: a randomized trial. | PSNet

    psnet.ahrq.gov/issue/effect-drug-concentration-expression-epinephrine-dosing-errors-randomized-trial
    August 27, 2008 - Study The effect of drug concentration expression on epinephrine dosing errors: a randomized trial. Citation Text: Wheeler DW, Carter JJ, Murray LJ, et al. The effect of drug concentration expression on epinephrine dosing errors: a randomized trial. Ann Intern Med. 2008;148(1):11-4. …

  13. Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018. | PSNet

    psnet.ahrq.gov/issue/adverse-events-hospitals-quarter-medicare-patients-experienced-harm-october-2018
    February 01, 2023 - Book/Report Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018. Citation Text: Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018. Grimm CA. Washington DC: Office of the Inspector General; May 2022. Repor…

  14. NPSD Data Spotlight, Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency, 2021. | PSNet

    psnet.ahrq.gov/issue/npsd-data-spotlight-patient-safety-and-covid-19-qualitative-analysis-concerns-during-public
    February 15, 2023 - Book/Report NPSD Data Spotlight, Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency, 2021. Citation Text: NPSD Data Spotlight, Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency, 2021. Rockvil…

  15. National Healthcare Quality and Disparities Report Chartbook on Patient Safety. | PSNet

    psnet.ahrq.gov/issue/national-healthcare-quality-and-disparities-report-chartbook-patient-safety-0
    May 02, 2017 - Book/Report National Healthcare Quality and Disparities Report Chartbook on Patient Safety. Citation Text: National Healthcare Quality and Disparities Report Chartbook on Patient Safety. Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Pub. No. 23-0046. Cop…

  16. To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. | PSNet

    psnet.ahrq.gov/issue/tell-truth-ethical-and-practical-issues-disclosing-medical-mistakes-patients
    April 19, 2011 - Commentary Classic To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. Citation Text: Wu AW, Cavanaugh TA, McPhee SJ, et al. To tell the truth. J Gen Intern Med. 2003;12(12). doi:10.1046/j.1525-1497.1997.07163.x. Copy …

  17. Effects of work hour reduction on residents' lives: a systematic review. | PSNet

    psnet.ahrq.gov/issue/effects-work-hour-reduction-residents-lives-systematic-review
    March 02, 2011 - Review Effects of work hour reduction on residents' lives: a systematic review. Citation Text: Fletcher KE, Underwood W, Davis SQ, et al. Effects of Work Hour Reduction on Residents’ Lives. JAMA. 2005;294(9):1088. doi:10.1001/jama.294.9.1088. Copy Citation Format: DOI Goo…

  18. The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals. | PSNet

    psnet.ahrq.gov/issue/girl-who-died-twice-every-patients-nightmare-libby-zion-case-and-hidden-hazards-hospitals
    May 09, 2018 - Book/Report Classic The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals. Citation Text: The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals. Robins NS…

  19. Culture as a Cure: Assessments of Patient Safety Culture in OECD Countries. | PSNet

    psnet.ahrq.gov/issue/culture-cure-assessments-patient-safety-culture-oecd-countries
    October 07, 2020 - Book/Report Culture as a Cure: Assessments of Patient Safety Culture in OECD Countries. Citation Text: Culture as a Cure: Assessments of Patient Safety Culture in OECD Countries. de Bienassisi K, Kristensenii S, Burtscheri M, et al for the Organisation for Economic Co-operation and …

  20. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. | PSNet

    psnet.ahrq.gov/issue/dual-process-cognitive-interventions-enhance-diagnostic-reasoning-systematic-review
    March 20, 2019 - Review Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. Citation Text: Lambe KA, O'Reilly G, Kelly BD, et al. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. BMJ Qual Saf. 2016;25(10):808-820. doi:10.113…
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