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Cultural transformation after implementation of crew resource management: is it really possible? | PSNet

psnet.ahrq.gov/issue/cultural-transformation-after-implementation-crew-resource-management-it-really-possible

November 16, 2022 - Study Cultural transformation after implementation of crew resource management: is it really possible? Citation Text: Hefner JL, Hilligoss B, Knupp A, et al. Cultural Transformation After Implementation of Crew Resource Management: Is It Really Possible? Am J Med Qual. 2017;32(4):384-390…

Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. | PSNet

psnet.ahrq.gov/issue/universal-screening-methicillin-resistant-staphylococcus-aureus-hospital-admission-and

January 27, 2021 - Study Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. Citation Text: Harbarth S, Fankhauser C, Schrenzel J, et al. Universal screening for methicillin-resistant Staphylococcus aureus at hospital ad…

Qualitative evaluation of the Safety and Improvement in Primary Care (SIPC) pilot collaborative in Scotland: perceptions and experiences of participating care teams. | PSNet

psnet.ahrq.gov/issue/qualitative-evaluation-safety-and-improvement-primary-care-sipc-pilot-collaborative-scotland

March 12, 2014 - Study Qualitative evaluation of the Safety and Improvement in Primary Care (SIPC) pilot collaborative in Scotland: perceptions and experiences of participating care teams. Citation Text: Bowie P, Halley L, Blamey A, et al. Qualitative evaluation of the Safety and Improvement in Primary C…

A qualitative formative evaluation of a patient-centred patient safety intervention delivered in collaboration with hospital volunteers. | PSNet

psnet.ahrq.gov/issue/qualitative-formative-evaluation-patient-centred-patient-safety-intervention-delivered

February 22, 2019 - Study A qualitative formative evaluation of a patient-centred patient safety intervention delivered in collaboration with hospital volunteers. Citation Text: Louch G, O'Hara JK, Mohammed MA. A qualitative formative evaluation of a patient-centred patient safety intervention delivered in …

Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes. | PSNet

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April 30, 2014 - Study Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes. Citation Text: Smits M, Janssen J, de Vet R, et al. Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and c…

The nature of the response to airway management incident reports in high income countries: a scoping review. | PSNet

psnet.ahrq.gov/issue/nature-response-airway-management-incident-reports-high-income-countries-scoping-review

December 15, 2014 - Review The nature of the response to airway management incident reports in high income countries: a scoping review. Citation Text: Endlich Y, Davies EL, Kelly J. The nature of the response to airway management incident reports in high income countries: a scoping review. Anaesth Intensive…

Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure mode and effects analysis. | PSNet

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March 09, 2022 - Study Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure mode and effects analysis. Citation Text: Manrique-Rodríguez S, Sánchez-Galindo AC, López-Herce J, et al. Risks in the implementation and use of smart pumps in a pediat…

Organizational response to known medical errors: does peer review protection impede improvement? | PSNet

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…

Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods. | PSNet

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January 19, 2022 - Study Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods. Citation Text: Payne CE, Stein JM, Leong T, et al. Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods. BMJ…

Decreasing prescribing errors in antimicrobial stewardship program-restricted medications. | PSNet

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September 25, 2024 - Study Decreasing prescribing errors in antimicrobial stewardship program-restricted medications. Citation Text: Tang KM, Lee P, Anosike BI, et al. Decreasing prescribing errors in antimicrobial stewardship program-restricted medications. Hosp Pediatr. 2024;14(4):281-290. doi:10.1542/hped…

A 38-year-old woman with fetal loss and hysterectomy. | PSNet

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January 12, 2011 - Commentary Classic A 38-year-old woman with fetal loss and hysterectomy. Citation Text: Sachs BP. A 38-Year-Old Woman With Fetal Loss and Hysterectomy. JAMA. 2005;294(7):833-840. doi:10.1001/jama.294.7.833. Copy Citation Format: DOI Google Schola…

Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. | PSNet

psnet.ahrq.gov/issue/dropping-baton-qualitative-analysis-failures-during-transition-emergency-department-inpatient

September 26, 2012 - Study Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Citation Text: Horwitz LI, Meredith T, Schuur JD, et al. Dropping the baton: a qualitative analysis of failures during the transition from emergency departmen…

Innovation in patient safety: a new task design in reducing patient falls. | PSNet

psnet.ahrq.gov/issue/innovation-patient-safety-new-task-design-reducing-patient-falls

January 04, 2010 - Study Innovation in patient safety: a new task design in reducing patient falls. Citation Text: Tzeng H-M, Yin C-Y. Innovation in patient safety: a new task design in reducing patient falls. J Nurs Care Qual. 2008;23(1):34-42. doi:10.1097/01.NCQ.0000303803.07457.e5. Copy Citation …

Association between implementation of an intensivist-led medical emergency team and mortality. | PSNet

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…

Five topics health care simulation can address to improve patient safety: results from a consensus process. | PSNet

psnet.ahrq.gov/issue/five-topics-health-care-simulation-can-address-improve-patient-safety-results-consensus

June 28, 2023 - Study Five topics health care simulation can address to improve patient safety: results from a consensus process. Citation Text: Sollid SJM, Dieckman P, Aase K, et al. Five Topics Health Care Simulation Can Address to Improve Patient Safety: Results From a Consensus Process. J Patient Sa…

Medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit. | PSNet

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…

Huddling for high reliability and situation awareness. | PSNet

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 …

Nighttime cross-coverage is associated with decreased intensive care unit mortality. A single-center study. | PSNet

psnet.ahrq.gov/issue/nighttime-cross-coverage-associated-decreased-intensive-care-unit-mortality-single-center

March 07, 2012 - Study Nighttime cross-coverage is associated with decreased intensive care unit mortality. A single-center study. Citation Text: Amaral ACK-B, Barros BS, Barros CCPP, et al. Nighttime cross-coverage is associated with decreased intensive care unit mortality. A single-center study. Am J R…

Medication errors reported by US family physicians and their office staff. | PSNet

psnet.ahrq.gov/issue/medication-errors-reported-us-family-physicians-and-their-office-staff

June 11, 2008 - Study Medication errors reported by US family physicians and their office staff. Citation Text: Kuo GM, Phillips RL, Graham D, et al. Medication errors reported by US family physicians and their office staff. Quality and Safety in Health Care. 2008;17(4). doi:10.1136/qshc.2007.024869. …

Accountability for medical error: moving beyond blame to advocacy. | PSNet

psnet.ahrq.gov/issue/accountability-medical-error-moving-beyond-blame-advocacy

December 19, 2018 - Review Accountability for medical error: moving beyond blame to advocacy. Citation Text: Bell SK, Delbanco T, Anderson-Shaw L, et al. Accountability for medical error: moving beyond blame to advocacy. Chest. 2011;140(2):519-526. doi:10.1378/chest.10-2533. Copy Citation Format: …

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