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  1. Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting. | PSNet

    psnet.ahrq.gov/issue/leading-clinical-handover-improvement-change-strategy-implement-best-practices-acute-care
    May 18, 2022 - Commentary Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting. Citation Text: Clarke CM, Persaud DD. Leading Clinical Handover Improvement. J Patient Saf. 2011;7(1):11-18. doi:10.1097/pts.0b013e31820c98a8. Copy Citation …

  2. A system analysis of a suboptimal surgical experience. | PSNet

    psnet.ahrq.gov/issue/system-analysis-suboptimal-surgical-experience
    March 23, 2011 - Study A system analysis of a suboptimal surgical experience. Citation Text: Lee R, Cooke DL, Richards MR. A system analysis of a suboptimal surgical experience. Patient Saf Surg. 2009;3(1):1. doi:10.1186/1754-9493-3-1. Copy Citation Format: DOI Google Scholar PubMed BibTe…

  3. Creating a safer operating room: groups, team dynamics and crew resource management principles. | PSNet

    psnet.ahrq.gov/issue/creating-safer-operating-room-groups-team-dynamics-and-crew-resource-management-principles
    June 11, 2008 - Review Emerging Classic Creating a safer operating room: groups, team dynamics and crew resource management principles. Citation Text: Wakeman D, Langham MR. Creating a safer operating room: Groups, team dynamics and crew resource management principles. Semin Pe…

  4. Identification of inpatient DNR status: a safety hazard begging for standardization. | PSNet

    psnet.ahrq.gov/issue/identification-inpatient-dnr-status-safety-hazard-begging-standardization
    January 19, 2012 - Study Identification of inpatient DNR status: a safety hazard begging for standardization. Citation Text: Sehgal NL, Wachter RM. Identification of inpatient DNR status: A safety hazard begging for standardization. J Hosp Med. 2007;2(6):366-371. doi:10.1002/jhm.283. Copy Citation …

  5. COVID-19 can last for several months. The disease’s “long-haulers” have endured relentless waves of debilitating symptoms—and disbelief from doctors and friends. | PSNet

    psnet.ahrq.gov/issue/covid-19-can-last-several-months-diseases-long-haulers-have-endured-relentless-waves
    April 03, 2005 - Newspaper/Magazine Article COVID-19 can last for several months. The disease’s “long-haulers” have endured relentless waves of debilitating symptoms—and disbelief from doctors and friends. Citation Text: Young E. COVID-19 can last for several months. The disease’s “long-haulers” have end…

  6. A practical approach to measure the quality of handwritten medication orders: a tool for improvement. | PSNet

    psnet.ahrq.gov/issue/practical-approach-measure-quality-handwritten-medication-orders-tool-improvement
    September 24, 2010 - Study A practical approach to measure the quality of handwritten medication orders: a tool for improvement. Citation Text: Garbutt J, Milligan P, McNaughton C, et al. A Practical Approach to Measure the Quality of Handwritten Medication Orders. J Patient Saf. 2008;1(4). doi:10.1097/01.…

  7. Using simulation to improve patient safety: dawn of a new era. | PSNet

    psnet.ahrq.gov/issue/using-simulation-improve-patient-safety-dawn-new-era
    October 29, 2017 - Commentary Using simulation to improve patient safety: dawn of a new era. Citation Text: Cheng A, Grant V, Auerbach M. Using simulation to improve patient safety: dawn of a new era. JAMA Pediatr. 2015;169(5):419-20. doi:10.1001/jamapediatrics.2014.3817. Copy Citation Format: …

  8. It's not all about me: motivating hand hygiene among health care professionals by focusing on patients. | PSNet

    psnet.ahrq.gov/issue/its-not-all-about-me-motivating-hand-hygiene-among-health-care-professionals-focusing
    May 29, 2019 - Study It's not all about me: motivating hand hygiene among health care professionals by focusing on patients. Citation Text: Grant AM, Hofmann DA. It's not all about me: motivating hand hygiene among health care professionals by focusing on patients. Psychol Sci. 2011;22(12):1494-9. do…

  9. Antecedents of severe and nonsevere medication errors. | PSNet

    psnet.ahrq.gov/issue/antecedents-severe-and-nonsevere-medication-errors
    February 15, 2011 - Study Antecedents of severe and nonsevere medication errors. Citation Text: Chang Y-K, Mark BA. Antecedents of severe and nonsevere medication errors. J Nurs Scholarsh. 2009;41(1):70-8. doi:10.1111/j.1547-5069.2009.01253.x. Copy Citation Format: DOI Google Scholar PubMed …

  10. Medication errors and response bias: the tip of the iceberg. | PSNet

    psnet.ahrq.gov/issue/medication-errors-and-response-bias-tip-iceberg
    February 07, 2024 - Study Medication errors and response bias: the tip of the iceberg. Citation Text: Bar-Oz B, Goldman M, Lahat E, et al. Medication errors and response bias: the tip of the iceberg. Isr Med Assoc J. 2008;10(11):771-4. Copy Citation Format: Google Scholar PubMed BibTeX EndN…

  11. The silence of the unblown whistle: the Nevada hepatitis C public health crisis. | PSNet

    psnet.ahrq.gov/issue/silence-unblown-whistle-nevada-hepatitis-c-public-health-crisis
    July 19, 2023 - Commentary The silence of the unblown whistle: the Nevada hepatitis C public health crisis. Citation Text: Leary E, Diers D. The silence of the unblown whistle: the Nevada hepatitis C public health crisis. Yale J Biol Med. 2013;86(1):79-87. Copy Citation Format: Google Sch…

  12. The Safe Tables Collaborative: a statewide experience. | PSNet

    psnet.ahrq.gov/issue/safe-tables-collaborative-statewide-experience
    April 12, 2011 - Commentary The Safe Tables Collaborative: a statewide experience. Citation Text: Wagner CA, Cecchettini D, Fletcher J. The safe tables collaborative: a statewide experience. Jt Comm J Qual Patient Saf. 2011;37(5):206-10, 193. Copy Citation Format: Google Scholar PubMed BibT…

  13. Nursing student medication errors: a snapshot view from a school of nursing's quality and safety officer. | PSNet

    psnet.ahrq.gov/issue/nursing-student-medication-errors-snapshot-view-school-nursings-quality-and-safety-officer
    October 19, 2022 - Commentary Nursing student medication errors: a snapshot view from a school of nursing's quality and safety officer. Citation Text: Cooper E. Nursing student medication errors: a snapshot view from a school of nursing's quality and safety officer. J Nurs Educ. 2014;53(3):S51-4. doi:10.…

  14. Improving diagnosis in health care—the next imperative for patient safety. | PSNet

    psnet.ahrq.gov/issue/improving-diagnosis-health-care-next-imperative-patient-safety
    July 15, 2015 - Commentary Classic Improving diagnosis in health care—the next imperative for patient safety. Citation Text: Singh H, Graber ML. Improving Diagnosis in Health Care--The Next Imperative for Patient Safety. New Engl J Med. 2015;373(26):2493-2495. doi:10.1056/NEJMp…

  15. Building nursing intellectual capital for safe use of information technology: a systematic review. | PSNet

    psnet.ahrq.gov/issue/building-nursing-intellectual-capital-safe-use-information-technology-systematic-review
    June 23, 2009 - Review Building nursing intellectual capital for safe use of information technology: a systematic review. Citation Text: Poe SS. Building nursing intellectual capital for safe use of information technology: a systematic review. J Nurs Care Qual. 2011;26(1):4-12. doi:10.1097/NCQ.0b013e31…

  16. One hospital's initiatives to encourage safe opioid use. | PSNet

    psnet.ahrq.gov/issue/one-hospitals-initiatives-encourage-safe-opioid-use
    October 19, 2022 - Commentary One hospital's initiatives to encourage safe opioid use. Citation Text: Surprise JK, Simpson MH. One Hospital's Initiatives to Encourage Safe Opioid Use. J Infus Nurs. 2015;38(4):278-83. doi:10.1097/NAN.0000000000000110. Copy Citation Format: DOI Google Scholar P…

  17. Impact of the Care Quality Commission on Provider Performance: Room for Improvement? | PSNet

    psnet.ahrq.gov/issue/impact-care-quality-commission-provider-performance-room-improvement
    November 18, 2015 - Book/Report Impact of the Care Quality Commission on Provider Performance: Room for Improvement? Citation Text: Impact of the Care Quality Commission on Provider Performance: Room for Improvement? Smithson R, Richardson E, Roberts J, et al. The King's Fund, Alliance Manchester Business S…

  18. Nursing handoffs: a systematic review of the literature. | PSNet

    psnet.ahrq.gov/issue/nursing-handoffs-systematic-review-literature
    January 08, 2025 - Review Nursing handoffs: a systematic review of the literature. Citation Text: Riesenberg LA, Leitzsch J, Cunningham JM. Nursing handoffs: a systematic review of the literature. Am J Nurs. 2010;110(4):24-34; quiz 35-6. doi:10.1097/01.NAJ.0000370154.79857.09. Copy Citation Format:…

  19. Hospital complications: linking payment reduction to preventability. | PSNet

    psnet.ahrq.gov/issue/hospital-complications-linking-payment-reduction-preventability
    July 13, 2010 - Commentary Hospital complications: linking payment reduction to preventability. Citation Text: Averill RE, Hughes JS, Goldfield NI, et al. Hospital complications: linking payment reduction to preventability. Jt Comm J Qual Patient Saf. 2009;35(5):283-5. Copy Citation Format: …

  20. What causes prescribing errors in children? Scoping review. | PSNet

    psnet.ahrq.gov/issue/what-causes-prescribing-errors-children-scoping-review
    September 09, 2015 - Review What causes prescribing errors in children? Scoping review. Citation Text: Conn RL, Kearney O, Tully MP, et al. What causes prescribing errors in children? Scoping review. BMJ Open. 2019;9(8):e028680. doi:10.1136/bmjopen-2018-028680. Copy Citation Format: DOI Google …
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