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Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality. | PSNet

psnet.ahrq.gov/issue/disorganized-care-findings-iterative-depth-analysis-surgical-morbidity-and-mortality

October 19, 2022 - Study Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality. Citation Text: Anderson CI, Nelson CS, Graham CF, et al. Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality. J Surg Res. 201…

Developing and implementing a standardized process for Global Trigger Tool application across a large health system. | PSNet

psnet.ahrq.gov/issue/developing-and-implementing-standardized-process-global-trigger-tool-application-across-large

July 18, 2017 - Study Developing and implementing a standardized process for Global Trigger Tool application across a large health system. Citation Text: Garrett PR, Sammer C, Nelson A, et al. Developing and implementing a standardized process for global trigger tool application across a large health …

Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System. | PSNet

psnet.ahrq.gov/issue/trends-healthcare-incident-reporting-and-relationship-safety-and-quality-data-acute-hospitals

March 28, 2011 - Study Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System. Citation Text: Hutchinson A, Young TA, Cooper KL, et al. Trends in healthcare incident reporting and relationship to sa…

Medication safety event reporting: factors that contribute to safety events during times of organizational stress. | PSNet

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June 21, 2023 - Study Medication safety event reporting: factors that contribute to safety events during times of organizational stress. Citation Text: Cohen TN, Berdahl CT, Coleman BL, et al. Medication safety event reporting: factors that contribute to safety events during times of organizational stre…

Systematic root cause analysis of adverse drug events in a tertiary referral hospital. | PSNet

psnet.ahrq.gov/issue/systematic-root-cause-analysis-adverse-drug-events-tertiary-referral-hospital

November 16, 2022 - Study Classic Systematic root cause analysis of adverse drug events in a tertiary referral hospital. Citation Text: Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary Referral Hospital. Jt Comm J Qual Improv…

Interactive questioning in critical care during handovers: a transcript analysis of communication behaviours by physicians, nurses and nurse practitioners. | PSNet

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August 11, 2021 - Study Interactive questioning in critical care during handovers: a transcript analysis of communication behaviours by physicians, nurses and nurse practitioners. Citation Text: Rayo MF, Mount-Campbell AF, O'Brien JM, et al. Interactive questioning in critical care during handovers: a tra…

A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in a United Kingdom hospital. | PSNet

psnet.ahrq.gov/issue/6-year-thematic-review-reported-incidents-associated-cardiopulmonary-resuscitation-calls

June 15, 2022 - Study A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in a United Kingdom hospital. Citation Text: Beed M, Hussain S, Woodier N, et al. A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in…

Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room. | PSNet

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October 07, 2013 - Study Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room. Citation Text: Bowermaster R, Miller M, Ashcraft T, et al. Application of the aviation black box principle in pediatric cardiac surgery: trac…

Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. | PSNet

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February 10, 2011 - Study Classic Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. Citation Text: Leape L, Cullen DJ, Clapp M, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. J…

Differing perceptions of safety culture across job roles in the ambulatory setting: analysis of the AHRQ Medical Office Survey on Patient Safety Culture. | PSNet

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March 15, 2017 - Study Differing perceptions of safety culture across job roles in the ambulatory setting: analysis of the AHRQ Medical Office Survey on Patient Safety Culture. Citation Text: Hickner J, Smith SA, Yount N, et al. Differing perceptions of safety culture across job roles in the ambulatory s…

Enhancing safety culture through improved incident reporting: a case study in translational research. | PSNet

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March 10, 2021 - Commentary Enhancing safety culture through improved incident reporting: a case study in translational research. Citation Text: Flott K, Nelson D, Moorcroft T, et al. Enhancing Safety Culture Through Improved Incident Reporting: A Case Study In Translational Research. Health Aff (Millwoo…

Do clinicians know which of their patients have central venous catheters?: A multicenter observational study. | PSNet

psnet.ahrq.gov/issue/do-clinicians-know-which-their-patients-have-central-venous-catheters-multicenter

June 08, 2016 - Study Do clinicians know which of their patients have central venous catheters?: A multicenter observational study. Citation Text: Chopra V, Govindan S, Kuhn L, et al. Do clinicians know which of their patients have central venous catheters?: a multicenter observational study. Ann Intern…

What stage are low-income and middle-income countries (LMICs) at with patient safety curriculum implementation and what are the barriers to implementation? A two-stage cross-sectional study. | PSNet

psnet.ahrq.gov/issue/what-stage-are-low-income-and-middle-income-countries-lmics-patient-safety-curriculum

October 23, 2019 - Study What stage are low-income and middle-income countries (LMICs) at with patient safety curriculum implementation and what are the barriers to implementation? A two-stage cross-sectional study. Citation Text: Ginsburg LR, Dhingra-Kumar N, Donaldson LJ. What stage are low-income and mi…

Differences in safety report event types submitted by graduate medical education trainees compared with other healthcare team members. | PSNet

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November 11, 2020 - Study Differences in safety report event types submitted by graduate medical education trainees compared with other healthcare team members. Citation Text: Cohen SP, McLean HS, Milne J, et al. Differences in Safety Report Event Types Submitted by Graduate Medical Education Trainees Compa…

Differences in hospitals' workplace violence incident reporting practices: a mixed methods study. | PSNet

psnet.ahrq.gov/issue/differences-hospitals-workplace-violence-incident-reporting-practices-mixed-methods-study

January 19, 2022 - Study Differences in hospitals' workplace violence incident reporting practices: a mixed methods study. Citation Text: Odes R, Chapman SM, Ackerman SL, et al. Differences in hospitals' workplace violence incident reporting practices: a mixed methods study. Policy Polit Nurs Pract. 2022;2…

Team relations and role perceptions during anesthesia crisis management in magnetic-resonance imaging settings: a mixed-methods exploration. | PSNet

psnet.ahrq.gov/issue/team-relations-and-role-perceptions-during-anesthesia-crisis-management-magnetic-resonance

December 13, 2023 - Study Team relations and role perceptions during anesthesia crisis management in magnetic-resonance imaging settings: a mixed-methods exploration. Citation Text: Schroeck H, Whitty MA, Hatton B, et al. Team relations and role perceptions during anesthesia crisis management in magnetic-re…

Parent willingness to remind health care workers to perform hand hygiene. | PSNet

psnet.ahrq.gov/issue/parent-willingness-remind-health-care-workers-perform-hand-hygiene

October 19, 2022 - Study Parent willingness to remind health care workers to perform hand hygiene. Citation Text: Buser GL, Fisher BT, Shea JA, et al. Parent willingness to remind health care workers to perform hand hygiene. Am J Infect Control. 2013;41(6):492-6. doi:10.1016/j.ajic.2012.08.006. Copy Cit…

Outbreak investigation of COVID-19 among residents and staff of an independent and assisted living community for older adults in Seattle, Washington. | PSNet

psnet.ahrq.gov/issue/outbreak-investigation-covid-19-among-residents-and-staff-independent-and-assisted-living

October 19, 2022 - Study Outbreak investigation of COVID-19 among residents and staff of an independent and assisted living community for older adults in Seattle, Washington. Citation Text: Roxby AC, Greninger AL, Hatfield KM, et al. Outbreak investigation of COVID-19 among residents and staff of an indepe…

Application of emergency preparedness principles to a pharmacy department’s approach to a “black swan” event: the COVID-19 pandemic. | PSNet

psnet.ahrq.gov/issue/application-emergency-preparedness-principles-pharmacy-departments-approach-black-swan-event

July 22, 2020 - Commentary Application of emergency preparedness principles to a pharmacy department’s approach to a “black swan” event: the COVID-19 pandemic. Citation Text: Waldron KM, Schenkat DH, Rao KV, et al. Application of emergency preparedness principles to a pharmacy department’s approach to a…

Improving health care quality and patient safety through peer-to-peer assessment: demonstration project in two academic medical centers. | PSNet

psnet.ahrq.gov/issue/improving-health-care-quality-and-patient-safety-through-peer-peer-assessment-demonstration

March 14, 2018 - Study Improving health care quality and patient safety through peer-to-peer assessment: demonstration project in two academic medical centers. Citation Text: Mort E, Bruckel J, Donelan K, et al. Improving Health Care Quality and Patient Safety Through Peer-to-Peer Assessment: Demonstrati…

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