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  1. Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic. | PSNet

    psnet.ahrq.gov/issue/infection-control-deficiencies-were-widespread-and-persistent-nursing-homes-prior-covid-19
    April 29, 2020 - Book/Report Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic. Citation Text: Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic. Washington, DC: United States Government Accoun…

  2. Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a "Never Event". | PSNet

    psnet.ahrq.gov/issue/classification-opioid-dependence-abuse-or-overdose-opioid-naive-patients-never-event
    September 21, 2022 - Commentary Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a "Never Event". Citation Text: Barth RJ, Waljee JF. Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a "Never Event". JAMA Surg. 2020;155(7):543-544. doi:10.…

  3. Building the bridge to quality: an urgent call to integrate quality improvement and patient safety education with clinical care | PSNet

    psnet.ahrq.gov/issue/building-bridge-quality-urgent-call-integrate-quality-improvement-and-patient-safety
    January 14, 2014 - Commentary Building the bridge to quality: an urgent call to integrate quality improvement and patient safety education with clinical care Citation Text: Wong BM, Baum KD, Headrick LA, et al. Building the bridge to quality: an urgent call to integrate quality improvement and patient safe…

  4. Hospital autopsy: endangered or extinct? | PSNet

    psnet.ahrq.gov/issue/hospital-autopsy-endangered-or-extinct
    November 21, 2021 - Study Hospital autopsy: endangered or extinct? Citation Text: Turnbull A, Osborn M, Nicholas N. Hospital autopsy: Endangered or extinct? J Clin Pathol. 2015;68(8):601-604. doi:10.1136/jclinpath-2014-202700. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 X…

  5. 'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports. | PSNet

    psnet.ahrq.gov/issue/connecting-dots-leveraging-visual-analytics-make-sense-patient-safety-event-reports
    May 29, 2024 - Commentary 'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports. Citation Text: Ratwani RM, Fong A. 'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports. J Am Med Inform Assoc. 2015;22(2):312-7. doi:1…

  6. An initiative to improve the management of clinically significant test results in a large health care network. | PSNet

    psnet.ahrq.gov/issue/initiative-improve-management-clinically-significant-test-results-large-health-care-network
    November 26, 2014 - Study An initiative to improve the management of clinically significant test results in a large health care network. Citation Text: Roy CL, Rothschild JM, Dighe AS, et al. An initiative to improve the management of clinically significant test results in a large health care network. Jt …

  7. Effect of a cluster randomised team training intervention on adverse perinatal and maternal outcomes: a stepped wedge study. | PSNet

    psnet.ahrq.gov/issue/effect-cluster-randomised-team-training-intervention-adverse-perinatal-and-maternal-outcomes
    April 04, 2018 - Study Effect of a cluster randomised team training intervention on adverse perinatal and maternal outcomes: a stepped wedge study. Citation Text: Romijn A, Ravelli A, de Bruijne MC, et al. Effect of a cluster randomised team training intervention on adverse perinatal and maternal outcome…

  8. Missed diagnosis of cardiovascular disease in outpatient general medicine: insights from malpractice claims data. | PSNet

    psnet.ahrq.gov/issue/missed-diagnosis-cardiovascular-disease-outpatient-general-medicine-insights-malpractice
    December 22, 2018 - Study Missed diagnosis of cardiovascular disease in outpatient general medicine: insights from malpractice claims data. Citation Text: Quinn GR, Ranum D, Song E, et al. Missed Diagnosis of Cardiovascular Disease in Outpatient General Medicine: Insights from Malpractice Claims Data. Jt Co…

  9. A comparative resident site visit project: a novel approach for implementing programmatic change in the duty hours era. | PSNet

    psnet.ahrq.gov/issue/comparative-resident-site-visit-project-novel-approach-implementing-programmatic-change-duty
    July 19, 2023 - Study A comparative resident site visit project: a novel approach for implementing programmatic change in the duty hours era. Citation Text: Crowley MJ, Barkauskas CE, Srygley D, et al. A comparative resident site visit project: a novel approach for implementing programmatic change in t…

  10. Hospital deaths in patients with sepsis from 2 independent cohorts. | PSNet

    psnet.ahrq.gov/issue/hospital-deaths-patients-sepsis-2-independent-cohorts
    November 21, 2021 - Study Hospital deaths in patients with sepsis from 2 independent cohorts. Citation Text: Liu V, Escobar GJ, Greene JD, et al. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA. 2014;312(1):90-2. Copy Citation Format: Google Scholar PubMed BibTeX EndNo…

  11. Sensemaking of patient safety risks and hazards. | PSNet

    psnet.ahrq.gov/issue/sensemaking-patient-safety-risks-and-hazards
    March 03, 2011 - Commentary Sensemaking of patient safety risks and hazards. Citation Text: Battles J, Dixon NM, Borotkanics RJ, et al. Sensemaking of patient safety risks and hazards. Health Serv Res. 2006;41(4 Pt 2):1555-1575. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X…

  12. Does a checklist reduce the number of errors made in nurse-assembled discharge prescriptions? | PSNet

    psnet.ahrq.gov/issue/does-checklist-reduce-number-errors-made-nurse-assembled-discharge-prescriptions
    March 24, 2019 - Study Does a checklist reduce the number of errors made in nurse-assembled discharge prescriptions? Citation Text: Byrne C, Sierra H, Tolhurst R. Does a checklist reduce the number of errors made in nurse-assembled discharge prescriptions? Br J Nurs. 2017;26(8):464-467. doi:10.12968/bjon…

  13. Patient safety in inpatient psychiatry: a remaining frontier for health policy. | PSNet

    psnet.ahrq.gov/issue/patient-safety-inpatient-psychiatry-remaining-frontier-health-policy
    October 19, 2022 - Commentary Patient safety in inpatient psychiatry: a remaining frontier for health policy. Citation Text: Shields MC, Stewart MT, Delaney KR. Patient Safety In Inpatient Psychiatry: A Remaining Frontier For Health Policy. Health Aff (Millwood). 2018;37(11):1853-1861. doi:10.1377/hlthaff.…

  14. A randomized trial of nighttime physician staffing in an intensive care unit. | PSNet

    psnet.ahrq.gov/issue/randomized-trial-nighttime-physician-staffing-intensive-care-unit
    September 23, 2020 - Study A randomized trial of nighttime physician staffing in an intensive care unit. Citation Text: Kerlin MP, Small DS, Cooney E, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;368(23):2201-9. doi:10.1056/NEJMoa1302854. Copy Ci…

  15. Endorsements of surgeon punishment and patient compensation in rested and sleep-restricted individuals. | PSNet

    psnet.ahrq.gov/issue/endorsements-surgeon-punishment-and-patient-compensation-rested-and-sleep-restricted
    September 23, 2020 - Study Endorsements of surgeon punishment and patient compensation in rested and sleep-restricted individuals. Citation Text: Nguyen S, Corrington A, Hebl MR, et al. Endorsements of Surgeon Punishment and Patient Compensation in Rested and Sleep-Restricted Individuals. JAMA Surg. 2019;154…

  16. Multidisciplinary medication review in nursing home residents: what are the most significant drug-related problems? The Bergen District Nursing Home (BEDNURS) study. | PSNet

    psnet.ahrq.gov/issue/multidisciplinary-medication-review-nursing-home-residents-what-are-most-significant-drug
    August 04, 2021 - Study Multidisciplinary medication review in nursing home residents: what are the most significant drug-related problems? The Bergen District Nursing Home (BEDNURS) study. Citation Text: Ruths S, Straand J, Nygaard HA. Multidisciplinary medication review in nursing home residents: what…

  17. Psychological responses, coping and supporting needs of healthcare professionals as second victims. | PSNet

    psnet.ahrq.gov/issue/psychological-responses-coping-and-supporting-needs-healthcare-professionals-second-victims
    August 20, 2018 - Review Psychological responses, coping and supporting needs of healthcare professionals as second victims. Citation Text: Chan ST, Khong PCB, Wang W. Psychological responses, coping and supporting needs of healthcare professionals as second victims. Intern Nurs Rev. 2017;64(2):242-262. d…

  18. The friends and family test: a qualitative study of concerns that influence the willingness of English National Health Service staff to recommend their organisation. | PSNet

    psnet.ahrq.gov/issue/friends-and-family-test-qualitative-study-concerns-influence-willingness-english-national
    May 01, 2015 - Study The friends and family test: a qualitative study of concerns that influence the willingness of English National Health Service staff to recommend their organisation. Citation Text: Dixon-Woods M, Minion JT, McKee L, et al. The friends and family test: a qualitative study of concern…

  19. The effects of power, leadership and psychological safety on resident event reporting. | PSNet

    psnet.ahrq.gov/issue/effects-power-leadership-and-psychological-safety-resident-event-reporting
    November 16, 2022 - Study The effects of power, leadership and psychological safety on resident event reporting. Citation Text: Appelbaum NP, Dow A, Mazmanian PE, et al. The effects of power, leadership and psychological safety on resident event reporting. Med Edu. 2016;50(3):343-350. doi:10.1111/medu.12947…

  20. Disclosure of "nonharmful" medical errors and other events: duty to disclose. | PSNet

    psnet.ahrq.gov/issue/disclosure-nonharmful-medical-errors-and-other-events-duty-disclose
    January 23, 2017 - Commentary Disclosure of "nonharmful" medical errors and other events: duty to disclose. Citation Text: Chamberlain CJ, Koniaris LG, Wu AW, et al. Disclosure of "nonharmful" medical errors and other events: duty to disclose. Arch Surg. 2012;147(3):282-6. doi:10.1001/archsurg.2011.1005. …
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