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psnet.ahrq.gov/issue/blood-bank-specimen-mislabeling-college-american-pathologists-q-probes-study-41333-blood-bank
November 16, 2022 - Study
Blood bank specimen mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions.
Citation Text:
Novis DA, Lindholm PF, Ramsey G, et al. Blood Bank Specimen Mislabeling: A College of American Pathologists Q-Probes Study of 41 333 …
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psnet.ahrq.gov/issue/biasing-influence-mental-shortcuts-diagnostic-decision-making-radiologists-can-overlook
April 07, 2021 - Study
Biasing influence of 'mental shortcuts' on diagnostic decision-making: radiologists can overlook breast cancer in mamograms when prior diagnostic information is available.
Citation Text:
Branch F, Santana I, Hegdé J. Biasing influence of 'mental shortcuts' on diagnostic decision-ma…
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psnet.ahrq.gov/issue/effects-enhanced-discharge-planning-intervention-hospitalized-older-adults-randomized-trial
September 21, 2016 - Study
Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial.
Citation Text:
Altfeld SJ, Shier GE, Rooney M, et al. Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial. Gerontologist.…
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psnet.ahrq.gov/issue/inattentional-blindness-anesthesiology-gorilla-worth-one-thousand-words
June 01, 2022 - Study
Inattentional blindness in anesthesiology: a gorilla is worth one thousand words.
Citation Text:
De Cassai A, Negro S, Geraldini F, et al. Inattentional blindness in anesthesiology: a gorilla is worth one thousand words. PLoS One. 2021;16(9):e0257508. doi:10.1371/journal.pone.02575…
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psnet.ahrq.gov/issue/characteristics-associated-requests-pathologists-second-opinions-breast-biopsies
November 03, 2015 - Study
Characteristics associated with requests by pathologists for second opinions on breast biopsies.
Citation Text:
Geller BM, Nelson HD, Weaver DL, et al. Characteristics associated with requests by pathologists for second opinions on breast biopsies. J Clin Pathol. 2017;70(11):947-95…
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psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patient-safety
February 14, 2024 - Commentary
Classic
Errors in laboratory medicine: practical lessons to improve patient safety.
Citation Text:
Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab Med. 2005;129(10):1252-1261.
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psnet.ahrq.gov/issue/wolf-crying-operating-room-patient-monitor-and-anesthesia-workstation-alarming-patterns
April 17, 2013 - Study
The wolf is crying in the operating room: patient monitor and anesthesia workstation alarming patterns during cardiac surgery.
Citation Text:
Schmid F, Goepfert MS, Kuhnt D, et al. The wolf is crying in the operating room: patient monitor and anesthesia workstation alarming patte…
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psnet.ahrq.gov/issue/fostering-just-culture-healthcare-organizations-experiences-practice
August 10, 2022 - Study
Fostering a just culture in healthcare organizations: experiences in practice.
Citation Text:
van Baarle E, Hartman L, Rooijakkers S, et al. Fostering a just culture in healthcare organizations: experiences in practice. BMC Health Serv Res. 2022;22(1):1035. doi:10.1186/s12913-022-0…
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psnet.ahrq.gov/issue/influence-stress-responses-surgical-performance-and-outcomes-literature-review-and
December 21, 2014 - Review
Emerging Classic
The influence of stress responses on surgical performance and outcomes: literature review and the development of the surgical stress effects (SSE) framework.
Citation Text:
Chrouser KL, Xu J, Hallbeck S, et al. The influence of stress res…
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psnet.ahrq.gov/issue/patient-safety-begins-proper-planning-quantitative-method-improve-hospital-design
July 19, 2023 - Study
Patient safety begins with proper planning: a quantitative method to improve hospital design.
Citation Text:
Birnbach DJ, Nevo I, Scheinman SR, et al. Patient safety begins with proper planning: a quantitative method to improve hospital design. Qual Saf Health Care. 2010;19(5):46…
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psnet.ahrq.gov/issue/establishing-psychological-safety-clinical-supervision-multi-professional-perspectives
October 13, 2021 - Commentary
Establishing psychological safety in clinical supervision: multi-professional perspectives.
Citation Text:
Lee EH, Pitts S, Pignataro S, et al. Establishing psychological safety in clinical supervision: multi‐professional perspectives. Clin Teach. 2022;19(2):71-78. doi:10.1111…
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psnet.ahrq.gov/issue/association-overlapping-surgery-patient-outcomes-large-series-neurosurgical-cases
November 16, 2022 - Study
Association of overlapping surgery with patient outcomes in a large series of neurosurgical cases.
Citation Text:
Howard BM, Holland CM, Mehta C, et al. Association of Overlapping Surgery With Patient Outcomes in a Large Series of Neurosurgical Cases. JAMA Surg. 2018;153(4):313-321…
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psnet.ahrq.gov/issue/getting-it-right-patient-safety-specimen-collection-process-improvement-operating-room
July 16, 2013 - Commentary
Getting it right for patient safety: specimen collection process improvement from operating room to pathology.
Citation Text:
D'Angelo R, Mejabi O. Getting It Right for Patient Safety: Specimen Collection Process Improvement From Operating Room to Pathology. Am J Clin Pathol.…
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psnet.ahrq.gov/issue/safety-first-using-checklist-intrafacility-transport-adult-intensive-care-patients
October 09, 2024 - Commentary
Safety first! Using a checklist for intrafacility transport of adult intensive care patients.
Citation Text:
Comeau OY, Armendariz-Batiste J, Woodby SA. Safety First! Using a Checklist for Intrafacility Transport of Adult Intensive Care Patients. Crit Care Nurse. 2015;35(5):16…
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psnet.ahrq.gov/issue/shape-matters-neglected-feature-medication-safety-why-regulating-shape-medication-containers
December 09, 2020 - Commentary
Shape matters: a neglected feature of medication safety: why regulating the shape of medication containers can improve medication safety.
Citation Text:
Bitan Y, Nunnally M. Shape matters: a neglected feature of medication safety: why regulating the shape of medication contain…
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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…
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psnet.ahrq.gov/issue/err-human-disclosure-must-be-taught-simulation-based-assessment-study
August 04, 2021 - Study
"To err is human" but disclosure must be taught: a simulation-based assessment study.
Citation Text:
Crimmins AC, Wong AH, Bonz JW, et al. "To Err Is Human" but Disclosure Must be Taught: A Simulation-Based Assessment Study. Simul Healthc. 2018;13(2):107-116. doi:10.1097/SIH.000000…
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psnet.ahrq.gov/issue/root-cause-analyses-suicides-mental-health-clients
March 16, 2016 - Study
Root cause analyses of suicides of mental health clients.
Citation Text:
Gillies D, Chicop D, O'Halloran P. Root Cause Analyses of Suicides of Mental Health Clients: Identifying Systematic Processes and Service-Level Prevention Strategies. Crisis. 2015;36(5):316-324. doi:10.1027/02…
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psnet.ahrq.gov/issue/review-healthcare-failure-mode-and-effects-analysis-hfmea-radiotherapy
June 13, 2011 - Review
A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy.
Citation Text:
Giardina M, Cantone MC, Tomarchio E, et al. A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. Health Phys. 2016;111(4):317-26. doi:10.1097/HP.0000000000…
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psnet.ahrq.gov/issue/improving-medication-administration-safety-using-naive-observation-assess-practice-and-guide
October 06, 2016 - Study
Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes.
Citation Text:
Donaldson N, Aydin C, Fridman M, et al. Improving medication administration safety: using naïve observation to assess practice and g…