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  1. System factors affecting intraoperative risk and resilience: applying a novel integrated approach to study surgical performance and patient safety. | PSNet

    psnet.ahrq.gov/issue/system-factors-affecting-intraoperative-risk-and-resilience-applying-novel-integrated
    August 25, 2021 - Study Emerging Classic System factors affecting intraoperative risk and resilience: applying a novel integrated approach to study surgical performance and patient safety. Citation Text: Kolodzey L, Trbovich PL, Kashfi A, et al. System Factors Affecting Intraope…

  2. What is the safety of nonemergent operative procedures performed at night? | PSNet

    psnet.ahrq.gov/issue/what-safety-nonemergent-operative-procedures-performed-night
    July 20, 2022 - Study What is the safety of nonemergent operative procedures performed at night? Citation Text: Turrentine FE, Wang H, Young JS, et al. What is the safety of nonemergent operative procedures performed at night? A study of 10,426 operations at an academic tertiary care hospital using th…

  3. Providers' and patients' perspectives on diagnostic errors in the acute care setting. | PSNet

    psnet.ahrq.gov/issue/providers-and-patients-perspectives-diagnostic-errors-acute-care-setting
    October 20, 2021 - Study Providers' and patients' perspectives on diagnostic errors in the acute care setting. Citation Text: Schnock KO, Garber A, Fraser H, et al. Providers' and patients' perspectives on diagnostic errors in the acute care setting. Jt Comm J Qual Patient Saf. 2023;49(2):89-97. doi:10.101…

  4. Safety events in pediatric out-of-hospital cardiac arrest. | PSNet

    psnet.ahrq.gov/issue/safety-events-pediatric-out-hospital-cardiac-arrest
    August 01, 2018 - Study Safety events in pediatric out-of-hospital cardiac arrest. Citation Text: Hansen M, Eriksson C, Skarica B, et al. Safety events in pediatric out-of-hospital cardiac arrest. Am J Emerg Med. 2018;36(3):380-383. doi:10.1016/j.ajem.2017.08.028. Copy Citation Format: DOI G…

  5. The next step in learning from sentinel events in healthcare. | PSNet

    psnet.ahrq.gov/issue/next-step-learning-sentinel-events-healthcare
    June 12, 2024 - Commentary The next step in learning from sentinel events in healthcare. Citation Text: Bos K, Dongelmans DA, Greuters S, et al. The next step in learning from sentinel events in healthcare. BMJ Open Qual. 2020;9(1):e000739. doi:10.1136/bmjoq-2019-000739. Copy Citation Format: …

  6. Scientific view of the global literature on medical error reporting and reporting systems from 1977 to 2021: a bibliometric analysis. | PSNet

    psnet.ahrq.gov/issue/scientific-view-global-literature-medical-error-reporting-and-reporting-systems-1977-2021
    October 19, 2022 - Review Scientific view of the global literature on medical error reporting and reporting systems from 1977 to 2021: a bibliometric analysis. Citation Text: Ünal A, Seren Intepeler Ş. Scientific view of the global literature on medical error reporting and reporting systems from 1977 to 20…

  7. The (commercialised) experience of operating: embodied preferences, ambiguous variations and explaining widespread patient harm. | PSNet

    psnet.ahrq.gov/issue/commercialised-experience-operating-embodied-preferences-ambiguous-variations-and-explaining
    August 24, 2022 - Study The (commercialised) experience of operating: embodied preferences, ambiguous variations and explaining widespread patient harm. Citation Text: Ducey A, Donoso C, Ross S, et al. The (commercialised) experience of operating: embodied preferences, ambiguous variations and explaining …

  8. A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety. | PSNet

    psnet.ahrq.gov/issue/qualitative-study-systemic-influences-paramedic-decision-making-care-transitions-and-patient
    January 08, 2014 - Study A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety. Citation Text: O'Hara R, Johnson M, Siriwardena N, et al. A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety. J He…

  9. Surgeons and systems working together to drive safety and quality. | PSNet

    psnet.ahrq.gov/issue/surgeons-and-systems-working-together-drive-safety-and-quality
    February 02, 2022 - Commentary Surgeons and systems working together to drive safety and quality. Citation Text: Hawkins RB, Nallamothu BK. Surgeons and systems working together to drive safety and quality. BMJ Qual Saf. 2023;32(4):181-184. doi:10.1136/bmjqs-2022-015045. Copy Citation Format: …

  10. Effectiveness of using simulation in the development of clinical reasoning in undergraduate nursing students: a systematic review. | PSNet

    psnet.ahrq.gov/issue/effectiveness-using-simulation-development-clinical-reasoning-undergraduate-nursing-students
    September 09, 2020 - Review Effectiveness of using simulation in the development of clinical reasoning in undergraduate nursing students: a systematic review. Citation Text: Theobald KA, Tutticci N, Ramsbotham J, et al. Effectiveness of using simulation in the development of clinical reasoning in undergradua…

  11. Body mass index category and adverse events in hospitalized children. | PSNet

    psnet.ahrq.gov/issue/body-mass-index-category-and-adverse-events-hospitalized-children
    August 03, 2022 - Study Body mass index category and adverse events in hospitalized children. Citation Text: Halvorson EE, Thurtle DP, Easter A, et al. Body mass index category and adverse events in hospitalized children. Acad Pediatr. 2022;22(5):747-753. doi:10.1016/j.acap.2021.09.004. Copy Citation …

  12. Diffusion of surgical innovations, patient safety, and minimally invasive radical prostatectomy. | PSNet

    psnet.ahrq.gov/issue/diffusion-surgical-innovations-patient-safety-and-minimally-invasive-radical-prostatectomy
    June 06, 2008 - Study Diffusion of surgical innovations, patient safety, and minimally invasive radical prostatectomy. Citation Text: Parsons K, Messer K, Palazzi K, et al. Diffusion of surgical innovations, patient safety, and minimally invasive radical prostatectomy. JAMA Surg. 2014;149(8):845-51. doi…

  13. Analysis of risk factors for patient safety events occurring in the emergency department. | PSNet

    psnet.ahrq.gov/issue/analysis-risk-factors-patient-safety-events-occurring-emergency-department
    January 26, 2022 - Study Analysis of risk factors for patient safety events occurring in the emergency department. Citation Text: Alsabri M, Boudi Z, Zoubeidi T, et al. Analysis of risk factors for patient safety events occurring in the emergency department. J Patient Saf. 2022;18(1):e124-e135. doi:10.1097…

  14. National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths. | PSNet

    psnet.ahrq.gov/issue/national-aeronautics-and-space-administration-threat-and-error-model-applied-pediatric
    March 07, 2018 - Study National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths. Citation Text: Hickey EJ, Nosikova Y, Pham-Hung E, et al. National Aeronautics and Space Administration "threat and error" model…

  15. Laboratory safety monitoring of chronic medications in ambulatory care settings. | PSNet

    psnet.ahrq.gov/issue/laboratory-safety-monitoring-chronic-medications-ambulatory-care-settings
    January 06, 2017 - Study Laboratory safety monitoring of chronic medications in ambulatory care settings. Citation Text: Hurley JS, Roberts M, Solberg LI, et al. Brief report: Laboratory safety monitoring of chronic medications in ambulatory care settings. J Gen Intern Med. 2005;20(4). doi:10.1111/j.1525…

  16. Pediatric patient safety events during hospitalization: approaches to accounting for institution-level effects. | PSNet

    psnet.ahrq.gov/issue/pediatric-patient-safety-events-during-hospitalization-approaches-accounting-institution
    December 23, 2012 - Study Pediatric patient safety events during hospitalization: approaches to accounting for institution-level effects. Citation Text: Slonim A, Marcin JP, Turenne W, et al. Pediatric patient safety events during hospitalization: approaches to accounting for institution-level effects. He…

  17. Organizational learning starting points and presuppositions: a case study from a hospital’s surgical department. | PSNet

    psnet.ahrq.gov/issue/organizational-learning-starting-points-and-presuppositions-case-study-hospitals-surgical
    September 25, 2024 - Study Organizational learning starting points and presuppositions: a case study from a hospital’s surgical department. Citation Text: Jaakkola M, Lemmetty S, Collin K, et al. Organizational learning starting points and presuppositions: a case study from a hospital’s surgical department. …

  18. Patients use an internet technology to report when things go wrong. | PSNet

    psnet.ahrq.gov/issue/patients-use-internet-technology-report-when-things-go-wrong
    July 21, 2009 - Study Patients use an internet technology to report when things go wrong. Citation Text: Wasson JH, MacKenzie TA, Hall M. Patients use an internet technology to report when things go wrong. Qual Saf Health Care. 2007;16(3):213-5. Copy Citation Format: Google Scholar PubMe…

  19. Medical line entanglement: the unspoken patient safety hazard of medical devices. | PSNet

    psnet.ahrq.gov/issue/medical-line-entanglement-unspoken-patient-safety-hazard-medical-devices
    May 08, 2019 - Study Medical line entanglement: the unspoken patient safety hazard of medical devices. Citation Text: Larimer C, Sumner V, Wander D. Medical line entanglement: the unspoken patient safety hazard of medical devices. Nutr Clin Pract. 2023;38(6):1296-1308. doi:10.1002/ncp.11000. Copy Cit…

  20. Hospital board checklist to improve culture and reduce central line–associated bloodstream infections. | PSNet

    psnet.ahrq.gov/issue/hospital-board-checklist-improve-culture-and-reduce-central-line-associated-bloodstream
    May 24, 2012 - Commentary Hospital board checklist to improve culture and reduce central line–associated bloodstream infections. Citation Text: Goeschel CA, Holzmueller CG, Pronovost P. Hospital Board Checklist to improve culture and reduce central line-associated bloodstream infections. Jt Comm J Qual…
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