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  1. Patient safety: moving the bar in prison health care standards. | PSNet

    psnet.ahrq.gov/issue/patient-safety-moving-bar-prison-health-care-standards
    August 28, 2024 - Commentary Patient safety: moving the bar in prison health care standards. Citation Text: Stern MF, Greifinger RB, Mellow J. Patient safety: moving the bar in prison health care standards. Am J Public Health. 2010;100(11):2103-2110. doi:10.2105/AJPH.2009.184242. Copy Citation For…

  2. Core competencies for patient safety research: a cornerstone for global capacity strengthening. | PSNet

    psnet.ahrq.gov/issue/core-competencies-patient-safety-research-cornerstone-global-capacity-strengthening
    September 15, 2021 - Commentary Core competencies for patient safety research: a cornerstone for global capacity strengthening. Citation Text: Andermann A, Ginsburg L, Norton P, et al. Core competencies for patient safety research: a cornerstone for global capacity strengthening. BMJ Qual Saf. 2011;20(1):9…

  3. What if?: Transforming Diagnostic Research by Leveraging a Diagnostic Process Map to Engage Patients in Learning from Errors. | PSNet

    psnet.ahrq.gov/issue/what-if-transforming-diagnostic-research-leveraging-diagnostic-process-map-engage-patients
    October 27, 2021 - Book/Report What if?: Transforming Diagnostic Research by Leveraging a Diagnostic Process Map to Engage Patients in Learning from Errors. Citation Text: Sheridan S, Merryweather P, Rusz D, et al. What If?: Transforming Diagnostic Research By Leveraging A Diagnostic Process Map To Engage …

  4. Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events. | PSNet

    psnet.ahrq.gov/issue/adverse-events-hospitals-medicares-responses-alleged-serious-events
    February 18, 2009 - Government Resource Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events. Citation Text: Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events. Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspecto…

  5. Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals. | PSNet

    psnet.ahrq.gov/issue/medicares-oversight-compounded-pharmaceuticals-used-hospitals
    October 16, 2012 - Government Resource Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals. Citation Text: Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals. Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January…

  6. Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems. | PSNet

    psnet.ahrq.gov/issue/few-adverse-events-hospitals-were-reported-state-adverse-event-reporting-systems
    January 20, 2010 - Book/Report Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems. Citation Text: Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems. Wright S. Washington, DC: US Department of Health and Human Services, Office of t…

  7. Addressing healthcare-associated infections and antimicrobial resistance from an organizational perspective: progress and challenges. | PSNet

    psnet.ahrq.gov/issue/addressing-healthcare-associated-infections-and-antimicrobial-resistance-organizational
    January 31, 2024 - Commentary Addressing healthcare-associated infections and antimicrobial resistance from an organizational perspective: progress and challenges. Citation Text: Murray E, Holmes A. Addressing healthcare-associated infections and antimicrobial resistance from an organizational perspectiv…

  8. Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel. | PSNet

    psnet.ahrq.gov/issue/teamwork-operating-room-frontline-perspectives-among-hospitals-and-operating-room-personnel
    February 10, 2015 - Study Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel. Citation Text: Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel. Sexton JB; Makary MA; Tersigni AR; Pryor D; Hendrich A; Thoma…

  9. Nature of human error: implications for surgical practice. | PSNet

    psnet.ahrq.gov/issue/nature-human-error-implications-surgical-practice
    March 24, 2021 - Review Nature of human error: implications for surgical practice. Citation Text: Cuschieri A. Nature of human error: implications for surgical practice. Ann Surg. 2006;244(5):642-8. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…

  10. Is health care getting safer? | PSNet

    psnet.ahrq.gov/issue/health-care-getting-safer
    December 14, 2016 - Commentary Is health care getting safer? Citation Text: Vincent CA, Aylin PP, Franklin BD, et al. Is health care getting safer? BMJ. 2008;337:a2426. doi:10.1136/bmj.a2426. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…

  11. Identifying and addressing preventable process errors in trauma care. | PSNet

    psnet.ahrq.gov/issue/identifying-and-addressing-preventable-process-errors-trauma-care
    June 17, 2015 - Study Identifying and addressing preventable process errors in trauma care. Citation Text: Pucher PH, Aggarwal R, Twaij A, et al. Identifying and addressing preventable process errors in trauma care. World J Surg. 2013;37(4):752-8. doi:10.1007/s00268-013-1917-9. Copy Citation Form…

  12. Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. | PSNet

    psnet.ahrq.gov/issue/protecting-patients-unsafe-system-etiology-and-recovery-intraoperative-deviations-care
    October 19, 2012 - Study Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. Citation Text: Hu Y-Y, Arriaga AF, Roth EM, et al. Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. Ann Surg. 2012;…

  13. Annotated bibliography: an update to: "Understanding ambulatory care practices in the context of patient safety and quality improvement." | PSNet

    psnet.ahrq.gov/issue/annotated-bibliography-understanding-ambulatory-care-practices-context-patient-safety-and
    March 02, 2010 - Commentary Annotated bibliography: an update to: "Understanding ambulatory care practices in the context of patient safety and quality improvement." Citation Text: Kumar PR, Nash DB. Annotated Bibliography: An Update to “Understanding Ambulatory Care Practices in the Context of Patient S…

  14. Critical role of the surgeon–anesthesiologist relationship for patient safety. | PSNet

    psnet.ahrq.gov/issue/critical-role-surgeon-anesthesiologist-relationship-patient-safety
    November 11, 2020 - Commentary Critical role of the surgeon–anesthesiologist relationship for patient safety. Citation Text: Cooper JB. Critical Role of the Surgeon-Anesthesiologist Relationship for Patient Safety. Anesthesiology. 2018;129(3):402-405. doi:10.1097/ALN.0000000000002324. Copy Citation Fo…

  15. Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams. | PSNet

    psnet.ahrq.gov/issue/errors-and-burden-errors-attitudes-perceptions-and-culture-safety-pediatric-cardiac-surgical
    June 16, 2019 - Study Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams. Citation Text: Bognár A, Barach P, Johnson J, et al. Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac sur…

  16. The "Quality Minute"—a new, brief, and structured technique for quality improvement education during the morbidity and mortality conference. | PSNet

    psnet.ahrq.gov/issue/quality-minute-new-brief-and-structured-technique-quality-improvement-education-during
    January 09, 2019 - Commentary The "Quality Minute"—a new, brief, and structured technique for quality improvement education during the morbidity and mortality conference. Citation Text: Hoffman RL, Morris JB, Kelz RR. The “Quality Minute”—A New, Brief, and Structured Technique for Quality Improvement Educa…

  17. Mandatory pharmacy residencies: one way to reduce medication errors. | PSNet

    psnet.ahrq.gov/issue/mandatory-pharmacy-residencies-one-way-reduce-medication-errors
    July 23, 2008 - Commentary Mandatory pharmacy residencies: one way to reduce medication errors. Citation Text: Ibrahim RB, Bahgat-Ibrahim L, Reeves D. Mandatory pharmacy residencies: One way to reduce medication errors. Am J Health Syst Pharm. 2010;67(6):477-81. doi:10.2146/ajhp090138. Copy Citation …

  18. Incidence and impact of physician and nurse disruptive behaviors in the emergency department. | PSNet

    psnet.ahrq.gov/issue/incidence-and-impact-physician-and-nurse-disruptive-behaviors-emergency-department
    February 03, 2010 - Study Incidence and impact of physician and nurse disruptive behaviors in the emergency department. Citation Text: Rosenstein AH, Naylor B. Incidence and impact of physician and nurse disruptive behaviors in the emergency department. J Emerg Med. 2012;43(1):139-48. doi:10.1016/j.jemerm…

  19. Why isn't 'time out' being implemented? An exploratory study. | PSNet

    psnet.ahrq.gov/issue/why-isnt-time-out-being-implemented-exploratory-study
    May 04, 2010 - Study Why isn't 'time out' being implemented? An exploratory study. Citation Text: Gillespie BM, Chaboyer W, Wallis M, et al. Why isn't 'time out' being implemented? An exploratory study. Qual Saf Health Care. 2010;19(2):103-6. doi:10.1136/qshc.2008.030593. Copy Citation Format: …

  20. Resident Safety Practices in Nursing Home Settings. | PSNet

    psnet.ahrq.gov/issue/resident-safety-practices-nursing-home-settings
    July 27, 2018 - Book/Report Resident Safety Practices in Nursing Home Settings. Citation Text: Resident Safety Practices in Nursing Home Settings. Simmons S, Schnelle J, Slagle J, et al. Technical Brief No. 24. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-…
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