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  1. A guide to evaluation of quality improvement and patient safety educational programs: lessons from the VA Chief Resident in Quality and Safety Program. | PSNet

    psnet.ahrq.gov/issue/guide-evaluation-quality-improvement-and-patient-safety-educational-programs-lessons-va-chief
    February 26, 2020 - Commentary A guide to evaluation of quality improvement and patient safety educational programs: lessons from the VA Chief Resident in Quality and Safety Program. Citation Text: Butcher RL, Carluzzo KL, Watts B, et al. A Guide to Evaluation of Quality Improvement and Patient Safety Educa…

  2. Quality of care and quality of life: balancing patient safety and physician burnout. | PSNet

    psnet.ahrq.gov/issue/quality-care-and-quality-life-balancing-patient-safety-and-physician-burnout
    September 27, 2023 - Commentary Quality of care and quality of life: balancing patient safety and physician burnout. Citation Text: Minkoff H, O'Brien J, Berkowitz R. Quality of care and quality of life: balancing patient safety and physician burnout. Obstet Gynecol. 2024;144(3):e50-e55. doi:10.1097/aog.0000…

  3. Anaesthesia and patient safety in the socio-technical operating theatre: a narrative review spanning a century. | PSNet

    psnet.ahrq.gov/issue/anaesthesia-and-patient-safety-socio-technical-operating-theatre-narrative-review-spanning
    April 10, 2024 - Review Anaesthesia and patient safety in the socio-technical operating theatre: a narrative review spanning a century. Citation Text: Webster CS, Mahajan R, Weller JM. Anaesthesia and patient safety in the socio-technical operating theatre: a narrative review spanning a century. Br J Ana…

  4. Team safety and innovation by learning from errors in long-term care settings. | PSNet

    psnet.ahrq.gov/issue/team-safety-and-innovation-learning-errors-long-term-care-settings
    March 05, 2010 - Study Team safety and innovation by learning from errors in long-term care settings. Citation Text: Buljac-Samardzic M, van Woerkom M, Paauwe J. Team safety and innovation by learning from errors in long-term care settings. Health Care Manage Rev. 2012;37(3):280-91. doi:10.1097/HMR.0b0…

  5. Human error and the problem of causality in analysis of accidents. | PSNet

    psnet.ahrq.gov/issue/human-error-and-problem-causality-analysis-accidents
    August 25, 2021 - Commentary Classic Human error and the problem of causality in analysis of accidents. Citation Text: Rasmussen J. Human error and the problem of causality in analysis of accidents. Philos Trans R Soc Lond B Biol Sci. 1990;327(1241):449-462. Copy Citation …

  6. Adverse events associated with home blood transfusion: a retrospective cohort study. | PSNet

    psnet.ahrq.gov/issue/adverse-events-associated-home-blood-transfusion-retrospective-cohort-study
    October 20, 2021 - Study Adverse events associated with home blood transfusion: a retrospective cohort study. Citation Text: Sharp R, Turner L, Altschwager J, et al. Adverse events associated with home blood transfusion: a retrospective cohort study. J Clin Nurs. 2021;30(11-12):1751-1759. doi:10.1111/jocn.…

  7. Standardizing opioid prescriptions to patients after ambulatory oncologic surgery reduces overprescription. | PSNet

    psnet.ahrq.gov/issue/standardizing-opioid-prescriptions-patients-after-ambulatory-oncologic-surgery-reduces
    October 19, 2022 - Study Standardizing opioid prescriptions to patients after ambulatory oncologic surgery reduces overprescription. Citation Text: Fearon NJ, Benfante N, Assel M, et al. Standardizing Opioid Prescriptions to Patients After Ambulatory Oncologic Surgery Reduces Overprescription. Jt Comm J Qu…

  8. Cognitive biases encountered by physicians in the emergency room. | PSNet

    psnet.ahrq.gov/issue/cognitive-biases-encountered-physicians-emergency-room
    June 19, 2024 - Study Cognitive biases encountered by physicians in the emergency room. Citation Text: Kunitomo K, Harada T, Watari T. Cognitive biases encountered by physicians in the emergency room. BMC Emerg Med. 2022;22(1):148. doi:10.1186/s12873-022-00708-3. Copy Citation Format: DOI …

  9. Comparing rates of adverse events and medical errors on inpatient psychiatric units at Veterans Health Administration and community-based general hospitals. | PSNet

    psnet.ahrq.gov/issue/comparing-rates-adverse-events-and-medical-errors-inpatient-psychiatric-units-veterans-health
    January 30, 2019 - Study Comparing rates of adverse events and medical errors on inpatient psychiatric units at Veterans Health Administration and community-based general hospitals. Citation Text: Cullen SW, Xie M, Vermeulen JM, et al. Comparing Rates of Adverse Events and Medical Errors on Inpatient Psych…

  10. Learning from non-routine events and teamwork in intensive care units: challenges and opportunities. | PSNet

    psnet.ahrq.gov/issue/learning-non-routine-events-and-teamwork-intensive-care-units-challenges-and-opportunities
    September 11, 2019 - Commentary Learning from non-routine events and teamwork in intensive care units: challenges and opportunities. Citation Text: Gong Y, Chen Y. Learning from non-routine events and teamwork in intensive care units: challenges and opportunities. Stud Health Technol Inform. 2024;310:324-328…

  11. Addressing ambulatory safety and malpractice: the Massachusetts PROMISES project. | PSNet

    psnet.ahrq.gov/issue/addressing-ambulatory-safety-and-malpractice-massachusetts-promises-project
    August 14, 2017 - Commentary Addressing ambulatory safety and malpractice: the Massachusetts PROMISES project. Citation Text: Schiff G, Nieva HR, Griswold P, et al. Addressing Ambulatory Safety and Malpractice: The Massachusetts PROMISES Project. Health Serv Res. 2016;51 Suppl 3:2634-2641. doi:10.1111/147…

  12. Preoperative site marking: are we adhering to good surgical practice? | PSNet

    psnet.ahrq.gov/issue/preoperative-site-marking-are-we-adhering-good-surgical-practice
    August 02, 2017 - Study Preoperative site marking: are we adhering to good surgical practice? Citation Text: Bathla S, Chadwick M, Nevins EJ, et al. Preoperative Site Marking. J Patient Saf. 2021;17(6):e503-e508. doi:10.1097/pts.0000000000000398. Copy Citation Format: DOI Google Scholar BibT…

  13. Are verbal orders a threat to patient safety? | PSNet

    psnet.ahrq.gov/issue/are-verbal-orders-threat-patient-safety
    July 31, 2008 - Review Are verbal orders a threat to patient safety? Citation Text: Wakefield DS, Wakefield BJ. Are verbal orders a threat to patient safety? Qual Saf Health Care. 2009;18(3):165-168. doi:10.1136/qshc.2009.034041. Copy Citation Format: DOI Google Scholar PubMed BibTeX End…

  14. Organizational climate determinants of resident safety culture in nursing homes. | PSNet

    psnet.ahrq.gov/issue/organizational-climate-determinants-resident-safety-culture-nursing-homes
    June 24, 2020 - Study Organizational climate determinants of resident safety culture in nursing homes. Citation Text: Arnetz JE, Zhdanova LS, Elsouhag D, et al. Organizational climate determinants of resident safety culture in nursing homes. Gerontologist. 2011;51(6):739-49. doi:10.1093/geront/gnr053.…

  15. We thought we would be perfect: medication errors before and after the initiation of computerized physician order entry. | PSNet

    psnet.ahrq.gov/issue/we-thought-we-would-be-perfect-medication-errors-and-after-initiation-computerized-physician
    September 18, 2019 - Study We thought we would be perfect: medication errors before and after the initiation of computerized physician order entry. Citation Text: Schwartzberg D, Ivanovic S, Patel S, et al. We thought we would be perfect: medication errors before and after the initiation of Computerized Phys…

  16. Crisis checklists in emergency medicine: another step forward for cognitive aids. | PSNet

    psnet.ahrq.gov/issue/crisis-checklists-emergency-medicine-another-step-forward-cognitive-aids
    April 21, 2021 - Commentary Crisis checklists in emergency medicine: another step forward for cognitive aids. Citation Text: Chen Y-YK, Arriaga AF. Crisis checklists in emergency medicine: another step forward for cognitive aids. BMJ Qual Saf. 2021;30(9):689-693. doi:10.1136/bmjqs-2021-013203. Copy Cit…

  17. Pediatric medication safety considerations for pharmacists in an adult hospital setting. | PSNet

    psnet.ahrq.gov/issue/pediatric-medication-safety-considerations-pharmacists-adult-hospital-setting
    January 29, 2020 - Commentary Pediatric medication safety considerations for pharmacists in an adult hospital setting. Citation Text: Kennedy AR, Massey LR. Pediatric medication safety considerations for pharmacists in an adult hospital setting. Am J Health Syst Pharm. 2019;76(19):1481-1491. doi:10.1093/aj…

  18. Use of nondisclosure agreements in medical malpractice settlements by a large academic health care system. | PSNet

    psnet.ahrq.gov/issue/use-nondisclosure-agreements-medical-malpractice-settlements-large-academic-health-care
    December 19, 2018 - Study Use of nondisclosure agreements in medical malpractice settlements by a large academic health care system. Citation Text: Sage WM, Jablonski JS, Thomas EJ. Use of Nondisclosure Agreements in Medical Malpractice Settlements by a Large Academic Health Care System. JAMA Intern Med. 20…

  19. Drug calculation ability of qualified paramedics: a pilot study. | PSNet

    psnet.ahrq.gov/issue/drug-calculation-ability-qualified-paramedics-pilot-study
    June 25, 2018 - Study Drug calculation ability of qualified paramedics: a pilot study. Citation Text: Boyle MJ, Eastwood K. Drug calculation ability of qualified paramedics: A pilot study. World J Emerg Med. 2018;9(1):41-45. doi:10.5847/wjem.j.1920-8642.2018.01.006. Copy Citation Format: D…

  20. Residents' numeric inputting error in computerized physician order entry prescription. | PSNet

    psnet.ahrq.gov/issue/residents-numeric-inputting-error-computerized-physician-order-entry-prescription
    March 24, 2019 - Study Residents' numeric inputting error in computerized physician order entry prescription. Citation Text: Wu X, Wu C, Zhang K, et al. Residents' numeric inputting error in computerized physician order entry prescription. Int J Med Inform. 2016;88:25-33. doi:10.1016/j.ijmedinf.2016.01.0…
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