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  1. Patient safety incidents in hospice care: observations from interdisciplinary case conferences. | PSNet

    psnet.ahrq.gov/issue/patient-safety-incidents-hospice-care-observations-interdisciplinary-case-conferences
    June 15, 2022 - Study Patient safety incidents in hospice care: observations from interdisciplinary case conferences. Citation Text: Oliver DP, Demiris G, Wittenberg-Lyles E, et al. Patient safety incidents in hospice care: observations from interdisciplinary case conferences. J Palliat Med. 2013;16(1…

  2. Implementation of a standardized postanesthesia care handoff increases information transfer without increasing handoff duration. | PSNet

    psnet.ahrq.gov/issue/implementation-standardized-postanesthesia-care-handoff-increases-information-transfer
    February 03, 2011 - Study Implementation of a standardized postanesthesia care handoff increases information transfer without increasing handoff duration. Citation Text: Caruso TJ, Marquez JL, Wu DS, et al. Implementation of a standardized postanesthesia care handoff increases information transfer without i…

  3. Applying lessons from social psychology to transform the culture of error disclosure. | PSNet

    psnet.ahrq.gov/issue/applying-lessons-social-psychology-transform-culture-error-disclosure
    March 20, 2024 - Commentary Applying lessons from social psychology to transform the culture of error disclosure. Citation Text: Han J, LaMarra D, Vapiwala N. Applying lessons from social psychology to transform the culture of error disclosure. Med Educ. 2017;51(10):996-1001. doi:10.1111/medu.13345. Co…

  4. Association between surgeon stress and major surgical complications. | PSNet

    psnet.ahrq.gov/issue/association-between-surgeon-stress-and-major-surgical-complications
    November 29, 2023 - Study Association between surgeon stress and major surgical complications. Citation Text: Awtry J, Skinner S, Polazzi S, et al. Association between surgeon stress and major surgical complications. JAMA Surg. 2025;160(3):332-340. doi:10.1001/jamasurg.2024.6072. Copy Citation Format:…

  5. Barriers to the reporting of medication administration errors and near misses: an interview study of nurses at a psychiatric hospital. | PSNet

    psnet.ahrq.gov/issue/barriers-reporting-medication-administration-errors-and-near-misses-interview-study-nurses
    September 27, 2017 - Study Barriers to the reporting of medication administration errors and near misses: an interview study of nurses at a psychiatric hospital. Citation Text: Haw C, Stubbs J, Dickens GL. Barriers to the reporting of medication administration errors and near misses: an interview study of nu…

  6. Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program. | PSNet

    psnet.ahrq.gov/issue/improving-perceptions-teamwork-climate-veterans-health-administration-medical-team-training
    December 21, 2014 - Study Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program. Citation Text: Carney BT, West P, Neily J, et al. Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program. Am J…

  7. Developing a high-performance team training framework for internal medicine residents: the ABC'S of teamwork. | PSNet

    psnet.ahrq.gov/issue/developing-high-performance-team-training-framework-internal-medicine-residents-abcs-teamwork
    June 01, 2011 - Study Developing a high-performance team training framework for internal medicine residents: the ABC'S of teamwork. Citation Text: Carbo AR, Tess A, Roy CL, et al. Developing a high-performance team training framework for internal medicine residents: the ABC'S of teamwork. J Patient Sa…

  8. Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future). | PSNet

    psnet.ahrq.gov/issue/measuring-patient-safety-medicare-patient-safety-monitoring-system-past-present-and-future
    December 18, 2014 - Review Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future). Citation Text: Classen D, Munier W, Verzier N, et al. Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future). J Patient Saf. 2021;17(3)…

  9. Patient safety in palliative care at the end of life from the perspective of complex thinking. | PSNet

    psnet.ahrq.gov/issue/patient-safety-palliative-care-end-life-perspective-complex-thinking
    October 05, 2022 - Commentary Patient safety in palliative care at the end of life from the perspective of complex thinking. Citation Text: Bittencourt NCC de M, Duarte S da CM, Marcon SS, et al. Patient safety in palliative care at the end of life from the perspective of complex thinking. Healthcare (Base…

  10. Improving the safety of medication administration using an interactive CD-ROM program. | PSNet

    psnet.ahrq.gov/issue/improving-safety-medication-administration-using-interactive-cd-rom-program
    February 15, 2011 - Commentary Improving the safety of medication administration using an interactive CD-ROM program. Citation Text: Schneider PJ, Pedersen CA, Montanya KR, et al. Improving the safety of medication administration using an interactive CD-ROM program. Am J Health Syst Pharm. 2006;63(1):59-6…

  11. Benefactor or burden: exploring the professional identity of safety professionals. | PSNet

    psnet.ahrq.gov/issue/benefactor-or-burden-exploring-professional-identity-safety-professionals
    October 11, 2017 - Study Benefactor or burden: exploring the professional identity of safety professionals. Citation Text: Provan DJ, Dekker SWA, Rae AJ. Benefactor or burden: Exploring the professional identity of safety professionals. J Safety Res. 2018;66:21-32. doi:10.1016/j.jsr.2018.05.005. Copy Cit…

  12. What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up. | PSNet

    psnet.ahrq.gov/issue/what-happened-my-patient-educational-intervention-facilitate-postdischarge-patient-follow
    June 22, 2022 - Commentary What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up. Citation Text: Narayana S, Rajkomar A, Harrison JD, et al. What Happened to My Patient? An Educational Intervention to Facilitate Postdischarge Patient Follow-Up. J Grad Med…

  13. Transforming concepts in patient safety: a progress report. | PSNet

    psnet.ahrq.gov/issue/transforming-concepts-patient-safety-progress-report
    January 20, 2015 - Review Classic Transforming concepts in patient safety: a progress report. Citation Text: Gandhi TK, Kaplan GS, Leape L, et al. Transforming concepts in patient safety: a progress report. BMJ Qual Saf. 2018;27(12):1019-1026. doi:10.1136/bmjqs-2017-007756. Copy…

  14. VHA's movement for change: implementing high-reliability principles and practices. | PSNet

    psnet.ahrq.gov/issue/vhas-movement-change-implementing-high-reliability-principles-and-practices
    August 21, 2024 - Commentary VHA's movement for change: implementing high-reliability principles and practices. Citation Text: Cox GR, Starr LM. VHA's movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68(3):151-157. doi:10.1097/jhm-d-23-00056. Copy Citati…

  15. Medication errors and trainees: advice for learners and organizations. | PSNet

    psnet.ahrq.gov/issue/medication-errors-and-trainees-advice-learners-and-organizations
    April 10, 2019 - Commentary Medication errors and trainees: advice for learners and organizations. Citation Text: Wheeler JS, Duncan R, Hohmeier K. Medication Errors and Trainees: Advice for Learners and Organizations. Ann Pharmacother. 2017;51(12):1138-1141. doi:10.1177/1060028017725092. Copy Citation…

  16. Inappropriate medications in elderly ICU survivors: where to intervene? | PSNet

    psnet.ahrq.gov/issue/inappropriate-medications-elderly-icu-survivors-where-intervene
    May 08, 2017 - Study Inappropriate medications in elderly ICU survivors: where to intervene? Citation Text: Morandi A, Vasilevskis EE, Pandharipande PP, et al. Inappropriate medications in elderly ICU survivors: where to intervene? Arch Intern Med. 2011;171(11):1032-4. doi:10.1001/archinternmed.2011.…

  17. Danger in discharge summaries: abbreviations create confusion for both author and recipient. | PSNet

    psnet.ahrq.gov/issue/danger-discharge-summaries-abbreviations-create-confusion-both-author-and-recipient
    March 15, 2017 - Study Danger in discharge summaries: abbreviations create confusion for both author and recipient. Citation Text: Coghlan A, Turner S, Coverdale S. Danger in discharge summaries: abbreviations create confusion for both author and recipient. Intern Med J. 2023;53(4):550-558. doi:10.1111/i…

  18. Negative behaviours in health care: prevalence and strategies. | PSNet

    psnet.ahrq.gov/issue/negative-behaviours-health-care-prevalence-and-strategies
    May 01, 2024 - Study Negative behaviours in health care: prevalence and strategies. Citation Text: Layne DM, Nemeth LS, Mueller M, et al. Negative behaviours in health care: Prevalence and strategies. J Nurs Manag. 2019;27(1):154-160. doi:10.1111/jonm.12660. Copy Citation Format: DOI Goog…

  19. Learning from excellence in healthcare: a new approach to incident reporting. | PSNet

    psnet.ahrq.gov/issue/learning-excellence-healthcare-new-approach-incident-reporting
    August 31, 2022 - Commentary Learning from excellence in healthcare: a new approach to incident reporting. Citation Text: Kelly N, Blake S, Plunkett A. Learning from excellence in healthcare: a new approach to incident reporting. Arch Dis Child. 2016;101(9):788-791. doi:10.1136/archdischild-2015-310021. …

  20. Utilizing pharmacy students in transitions-of-care services. | PSNet

    psnet.ahrq.gov/issue/utilizing-pharmacy-students-transitions-care-services
    October 19, 2022 - Commentary Utilizing pharmacy students in transitions-of-care services. Citation Text: L'Hommedieu T, DeCoske M, Lababidi RE, et al. Utilizing pharmacy students in transitions-of-care services. Am J Health Syst Pharm. 2015;72(15):1266-8. doi:10.2146/ajhp140561. Copy Citation Format…
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