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psnet.ahrq.gov/issue/preventable-anesthesia-mishaps-study-human-factors
June 23, 2015 - Study
Classic
Preventable anesthesia mishaps: a study of human factors.
Citation Text:
Cooper JB, Newbower RS, Long CD, et al. Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978;49(6):399-406.
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psnet.ahrq.gov/issue/identifying-high-alert-medications-university-hospital-applying-data-medication-error
August 03, 2017 - Study
Identifying high-alert medications in a university hospital by applying data from the medication error reporting system.
Citation Text:
Tyynismaa L, Honkala A, Airaksinen M, et al. Identifying High-alert Medications in a University Hospital by Applying Data From the Medication Erro…
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psnet.ahrq.gov/issue/critical-issues-food-allergy-national-academies-consensus-report
November 16, 2022 - Commentary
Critical Issues in Food Allergy: A National Academies Consensus Report.
Citation Text:
Sicherer SH, Allen K, Lack G, et al. Critical Issues in Food Allergy: A National Academies Consensus Report. Pediatrics. 2017;140(2). doi:10.1542/peds.2017-0194.
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psnet.ahrq.gov/issue/understanding-procedural-violations-using-safety-i-and-safety-ii-case-community-pharmacies
February 06, 2019 - Study
Understanding procedural violations using Safety-I and Safety-II: the case of community pharmacies.
Citation Text:
Jones CEL, Phipps D, Ashcroft DM. Understanding procedural violations using Safety-I and Safety-II: The case of community pharmacies. Saf Sci. 2018;105:114-120. doi:10…
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psnet.ahrq.gov/issue/using-situ-simulation-improve-hospital-cardiopulmonary-resuscitation
January 02, 2017 - Study
Using in situ simulation to improve in-hospital cardiopulmonary resuscitation.
Citation Text:
Lighthall GK, Poon T, Harrison K. Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. Jt Comm J Qual Patient Saf. 2010;36(5):209-16.
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psnet.ahrq.gov/issue/emergency-department-patient-safety-incident-characterization-observational-analysis-findings
July 29, 2020 - Study
Emergency department patient safety incident characterization: an observational analysis of the findings of a standardized peer review process.
Citation Text:
Jepson ZK, Darling CE, Kotkowski KA, et al. Emergency department patient safety incident characterization: an observational…
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psnet.ahrq.gov/issue/impact-shift-patterns-junior-doctors-perceptions-fatigue-training-worklife-balance-and-role
March 14, 2022 - Study
The impact of shift patterns on junior doctors' perceptions of fatigue, training, work/life balance and the role of social support.
Citation Text:
Brown M, Tucker P, Rapport F, et al. The impact of shift patterns on junior doctors' perceptions of fatigue, training, work/life bala…
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psnet.ahrq.gov/issue/do-safety-briefings-improve-patient-safety-acute-hospital-setting-systematic-review
August 14, 2024 - Review
Do safety briefings improve patient safety in the acute hospital setting? A systematic review.
Citation Text:
Ryan S, Ward M, Vaughan D, et al. Do safety briefings improve patient safety in the acute hospital setting? A systematic review. J Adv Nurs. 2019;75(10):2085-2098. doi:10.…
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psnet.ahrq.gov/issue/clinical-staging-error-prostate-cancer-localization-and-relevance-undetected-tumour-areas
April 21, 2021 - Study
Clinical staging error in prostate cancer: localization and relevance of undetected tumour areas.
Citation Text:
Bolenz C, Gierth M, Grobholz R, et al. Clinical staging error in prostate cancer: localization and relevance of undetected tumour areas. BJU Int. 2009;103(9):1184-9. d…
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psnet.ahrq.gov/issue/effect-opioid-prescribing-guidelines-prescriptions-emergency-physicians-ohio
April 24, 2018 - Study
The effect of opioid prescribing guidelines on prescriptions by emergency physicians in Ohio.
Citation Text:
Weiner SG, Baker O, Poon SJ, et al. The Effect of Opioid Prescribing Guidelines on Prescriptions by Emergency Physicians in Ohio. Ann Emerg Med. 2017;70(6):799-808.e1. doi:1…
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psnet.ahrq.gov/issue/monitoring-during-sedation-given-non-anaesthetic-doctors
August 30, 2023 - Study
Monitoring during sedation given by non-anaesthetic doctors.
Citation Text:
Fanning RM. Monitoring during sedation given by non-anaesthetic doctors. Anaesthesia. 2008;63(4):370-374. doi:10.1111/j.1365-2044.2007.05378.x.
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psnet.ahrq.gov/issue/factors-underlying-suboptimal-diagnostic-performance-physicians-under-time-pressure
June 01, 2016 - Study
Factors underlying suboptimal diagnostic performance in physicians under time pressure.
Citation Text:
ALQahtani DA, Rotgans JI, Mamede S, et al. Factors underlying suboptimal diagnostic performance in physicians under time pressure. Med Educ. 2018;52(12):1288-1298. doi:10.1111/med…
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psnet.ahrq.gov/issue/surgical-adverse-outcomes-and-patients-evaluation-quality-care-inherent-risk-or-reduced
March 22, 2011 - Study
Surgical adverse outcomes and patients’ evaluation of quality of care: inherent risk or reduced quality of care?
Citation Text:
van de Mheen PJM-, van Duijn-Bakker N, Kievit J. Surgical adverse outcomes and patients' evaluation of quality of care: inherent risk or reduced quality…
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psnet.ahrq.gov/issue/ethics-empowering-patients-partners-healthcare-associated-infection-prevention
January 04, 2019 - Commentary
The ethics of empowering patients as partners in healthcare-associated infection prevention.
Citation Text:
Sharp D, Palmore T, Grady C. The ethics of empowering patients as partners in healthcare-associated infection prevention. Infect Control Hosp Epidemiol. 2014;35(3):307-9…
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psnet.ahrq.gov/issue/operative-team-communication-during-simulated-emergencies-too-busy-respond
March 04, 2020 - Study
Operative team communication during simulated emergencies: too busy to respond?
Citation Text:
Davis A, Jones S, Crowell-Kuhnberg AM, et al. Operative team communication during simulated emergencies: Too busy to respond? Surgery. 2017;161(5):1348-1356. doi:10.1016/j.surg.2016.09.02…
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psnet.ahrq.gov/issue/acute-hepatitis-c-virus-infections-attributed-unsafe-injection-practices-endoscopy-clinic
February 27, 2019 - Government Resource
Acute Hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic—Nevada, 2007.
Citation Text:
Prevention C for DC and. Acute hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic--Nevada, 2007.…
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www.ahrq.gov/teamstepps-program/evidence-base/hospital.html
June 01, 2023 - TeamSTEPPS Research/Evidence Base: Hospital
Baloh J, Zhu X, Ward MM. What influences sustainment and nonsustainment of facilitation activities in implementation? Analysis of organizational factors in hospitals implementing TeamSTEPPS. Med Care Res Rev. 2021;78(2):146-56. Epub 2019/05/17. doi: 10.1177/10775587…
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psnet.ahrq.gov/issue/determinants-patient-reported-medication-errors-comparison-among-seven-countries
July 29, 2020 - Study
Determinants of patient-reported medication errors: a comparison among seven countries.
Citation Text:
Lu CY, Roughead E. Determinants of patient-reported medication errors: a comparison among seven countries. Int J Clin Pract. 2011;65(7):733-40. doi:10.1111/j.1742-1241.2011.0267…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/training/cbt-iodophor.pptx
March 01, 2022 - Computer-Based Training Modules: Nasal Iodophor
Decolonization of
Non-ICU Patients With Devices
Section 11-8
Nursing Protocol Training
Nasal Iodophor (10% Povidone-Iodine)
AHRQ Pub. No. 20(22)-0036
March 2022
1
Targeted Decolonization Introduction
Our hospital is adopting a targeted decolonization protocol for …
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psnet.ahrq.gov/issue/vaccination-errors-general-practice-creation-preventive-checklist-based-multimodal-analysis
July 08, 2020 - Study
Vaccination errors in general practice: creation of a preventive checklist based on a multimodal analysis of declared errors.
Citation Text:
Charles R, Vallée J, Tissot C, et al. Vaccination errors in general practice: creation of a preventive checklist based on a multimodal analys…