-
psnet.ahrq.gov/issue/patient-safety-factors-children-dying-paediatric-intensive-care-unit-picu-case-notes-review
December 03, 2014 - Study
Patient safety factors in children dying in a paediatric intensive care unit (PICU): a case notes review study.
Citation Text:
Monroe K, Wang D, Vincent CA, et al. Patient safety factors in children dying in a paediatric intensive care unit (PICU): a case notes review study. BMJ …
-
psnet.ahrq.gov/issue/overlooked-guide-wire-multicomplicated-swiss-cheese-model-example-analysis-case-and-review
September 15, 2021 - Commentary
Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature.
Citation Text:
Thonon H, Espeel F, Frederic F, et al. Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of t…
-
psnet.ahrq.gov/issue/impact-prolonged-continuous-wakefulness-resident-clinical-performance-intensive-care-unit
November 21, 2016 - Study
The impact of prolonged continuous wakefulness on resident clinical performance in the intensive care unit: a patient simulator study.
Citation Text:
Sharpe R, Koval V, Ronco JJ, et al. The impact of prolonged continuous wakefulness on resident clinical performance in the intensi…
-
psnet.ahrq.gov/issue/preoperative-communication-between-anesthesia-surgery-and-primary-care-providers-older
April 11, 2011 - Study
Preoperative communication between anesthesia, surgery, and primary care providers for older surgical patients.
Citation Text:
Ron D, Gunn CM, Havidich JE, et al. Preoperative communication between anesthesia, surgery, and primary care providers for older surgical patients. Jt Comm…
-
psnet.ahrq.gov/issue/overview-patient-safety-climate-va
January 10, 2017 - Study
An overview of patient safety climate in the VA.
Citation Text:
Hartmann CW, Rosen AK, Meterko M, et al. An overview of patient safety climate in the VA. Health Serv Res. 2008;43(4):1263-84. doi:10.1111/j.1475-6773.2008.00839.x.
Copy Citation
Format:
DOI Google Scho…
-
psnet.ahrq.gov/issue/organizational-response-known-medical-errors-does-peer-review-protection-impede-improvement
April 24, 2018 - Commentary
Organizational response to known medical errors: does peer review protection impede improvement?
Citation Text:
Wenner WJ, Choi SW. Organizational Response to Known Medical Errors: Does Peer Review Protection Impede Improvement? Am J Med Qual. 2018;33(5):552-553. doi:10.1177/1…
-
psnet.ahrq.gov/issue/impact-reduction-working-hours-doctors-training-postgraduate-medical-education-and-patients
November 10, 2010 - Review
Impact of reduction in working hours for doctors in training on postgraduate medical education and patients' outcomes: systematic review.
Citation Text:
Moonesinghe SR, Lowery J, Shahi N, et al. Impact of reduction in working hours for doctors in training on postgraduate medical…
-
psnet.ahrq.gov/issue/confidential-clinician-reported-surveillance-adverse-events-among-medical-inpatients
June 29, 2011 - Study
Classic
Confidential clinician-reported surveillance of adverse events among medical inpatients.
Citation Text:
Weingart SN, Ship AN, Aronson MD. Confidential clinician-reported surveillance of adverse events among medical inpatients. J Gen Intern Med. 2…
-
psnet.ahrq.gov/issue/association-between-implementation-intensivist-led-medical-emergency-team-and-mortality
July 13, 2010 - Study
Association between implementation of an intensivist-led medical emergency team and mortality.
Citation Text:
Karvellas CJ, de Souza IAO, Gibney RTN, et al. Association between implementation of an intensivist-led medical emergency team and mortality. BMJ Qual Saf. 2012;21(2):152…
-
psnet.ahrq.gov/issue/emergency-hospitalizations-unsupervised-prescription-medication-ingestions-young-children
April 22, 2020 - Study
Emergency hospitalizations for unsupervised prescription medication ingestions by young children.
Citation Text:
Lovegrove MC, Mathew J, Hampp C, et al. Emergency hospitalizations for unsupervised prescription medication ingestions by young children. Pediatrics. 2014;134(4):e1009-1…
-
psnet.ahrq.gov/issue/theoretical-model-flow-disruptions-anesthesia-team-during-cardiovascular-surgery
July 21, 2021 - Study
A theoretical model of flow disruptions for the anesthesia team during cardiovascular surgery.
Citation Text:
Boquet A, Cohen T, Diljohn F, et al. A theoretical model of flow disruptions for the anesthesia team during cardiovascular surgery. J Patient Saf. 2021;17(6):e534-e539. doi…
-
psnet.ahrq.gov/issue/medication-errors-caregivers-home-neonates-discharged-neonatal-intensive-care-unit
June 07, 2023 - Study
Medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit.
Citation Text:
Solanki R, Mondal N, Mahalakshmy T, et al. Medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit. Arch Dis Child. 2017…
-
psnet.ahrq.gov/issue/confronting-safety-gaps-across-labor-and-delivery-teams
December 04, 2013 - Study
Confronting safety gaps across labor and delivery teams.
Citation Text:
Maxfield DG, Lyndon A, Kennedy HP, et al. Confronting safety gaps across labor and delivery teams. Am J Obstet Gynecol. 2013;209(5). doi:10.1016/j.ajog.2013.07.013.
Copy Citation
Format:
DOI Googl…
-
psnet.ahrq.gov/issue/huddling-high-reliability-and-situation-awareness
January 29, 2014 - Study
Huddling for high reliability and situation awareness.
Citation Text:
Goldenhar LM, Brady PW, Sutcliffe K, et al. Huddling for high reliability and situation awareness. BMJ Qual Saf. 2013;22(11):899-906. doi:10.1136/bmjqs-2012-001467.
Copy Citation
Format:
DOI Google …
-
psnet.ahrq.gov/issue/missed-rationed-or-unfinished-nursing-care-scoping-review-patient-outcomes
May 29, 2024 - Review
Missed, rationed or unfinished nursing care: a scoping review of patient outcomes.
Citation Text:
Kalánková D, Kirwan M, Bartoníčková D, et al. Missed, rationed or unfinished nursing care: A scoping review of patient outcomes. J Nurs Manag. 2020;28(8):1783-1797. doi:10.1111/jonm.1…
-
psnet.ahrq.gov/issue/multi-level-analysis-national-nursing-students-disclosure-patient-safety-concerns
April 28, 2021 - Study
Multi-level analysis of national nursing students' disclosure of patient safety concerns.
Citation Text:
Palese A, Gonella S, Grassetti L, et al. Multi-level analysis of national nursing students' disclosure of patient safety concerns. Med Educ. 2018;52(11):1156-1166. doi:10.1111/m…
-
psnet.ahrq.gov/issue/accreditation-council-graduate-medical-education-resident-duty-hour-new-standards-history
November 21, 2021 - Commentary
The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units.
Citation Text:
Pastores SM, O'Connor MF, Kleinpell R, et al. The Accreditation Council for Graduate Medical Education …
-
psnet.ahrq.gov/issue/changes-hospital-mortality-associated-residency-work-hour-regulations
May 27, 2011 - Study
Classic
Changes in hospital mortality associated with residency work-hour regulations.
Citation Text:
Shetty KD, Bhattacharya J. Changes in hospital mortality associated with residency work-hour regulations. Ann Intern Med. 2007;147(2):73-80.
Copy Cit…
-
psnet.ahrq.gov/issue/systematic-review-physiologic-monitor-alarm-characteristics-and-pragmatic-interventions
August 03, 2017 - Review
Classic
Systematic review of physiologic monitor alarm characteristics and pragmatic interventions to reduce alarm frequency.
Citation Text:
Paine CW, Goel V, Ely E, et al. Systematic Review of Physiologic Monitor Alarm Characteristics and Pragmatic Inter…
-
www.ahrq.gov/news/newsroom/case-studies/coe1304.html
April 01, 2013 - Maryland Guides Prescribers on Use of Atypical Antipsychotic Medications
Search All Impact Case Studies
April 2013
The Maryland Department of Health and Mental Hygiene used materials created by AHRQ's Effective Health Care Program to help set up a new program for appropriate use of antipsychotic medications…