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psnet.ahrq.gov/issue/prevention-wrong-location-misadministration-through-use-intradepartmental-incident-learning
January 22, 2017 - Study
Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system.
Citation Text:
Ford E, Smith K, Harris K, et al. Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system. M…
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psnet.ahrq.gov/issue/improving-radiology-report-quality-rapidly-notifying-radiologist-report-errors
May 29, 2019 - Study
Improving radiology report quality by rapidly notifying radiologist of report errors.
Citation Text:
Minn MJ, Zandieh AR, Filice RW. Improving Radiology Report Quality by Rapidly Notifying Radiologist of Report Errors. J Digit Imaging. 2015;28(4):492-8. doi:10.1007/s10278-015-9781-…
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psnet.ahrq.gov/issue/confused-and-bewildered-hospital-adverse-event-discovery-pay-performance-and-big-data-tools
September 23, 2020 - Commentary
The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technologies.
Citation Text:
Furrow BR. The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technolog…
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psnet.ahrq.gov/issue/whats-past-prologue-organizational-learning-serious-patient-injury
October 26, 2011 - Study
What’s past is prologue: organizational learning from a serious patient injury.
Citation Text:
Tamuz M, Franchois KE, Thomas EJ. What’s past is prologue: Organizational learning from a serious patient injury. Saf Sci. 2010;49(1). doi:10.1016/j.ssci.2010.06.005.
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psnet.ahrq.gov/issue/prospective-hazard-and-improvement-analytic-approach-predicting-effectiveness-medication
December 04, 2013 - Study
A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions.
Citation Text:
Karnon J, McIntosh A, Dean JE, et al. A prospective hazard and improvement analytic approach to predicting the effectiveness of medication erro…
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psnet.ahrq.gov/issue/patient-safety-culture-primary-care-developing-theoretical-framework-practical-use
September 06, 2017 - Study
Patient safety culture in primary care: developing a theoretical framework for practical use.
Citation Text:
Kirk S, Parker D, Claridge T, et al. Patient safety culture in primary care: developing a theoretical framework for practical use. Qual Saf Health Care. 2007;16(4):313-20.…
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psnet.ahrq.gov/issue/integrating-systemic-accident-analysis-patient-safety-incident-investigation-practices
October 27, 2021 - Study
Integrating systemic accident analysis into patient safety incident investigation practices.
Citation Text:
Canham A, Jun GT, Waterson P, et al. Integrating systemic accident analysis into patient safety incident investigation practices. Appl Ergon. 2018;72:1-9. doi:10.1016/j.aperg…
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psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-useful-proactive-risk-analysis-pediatric
June 13, 2011 - Study
Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology ward.
Citation Text:
van Tilburg CM, Leistikow IP, Rademaker CMA, et al. Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology w…
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psnet.ahrq.gov/issue/power-written-word-reflection-reduces-errors-omission
April 24, 2018 - Study
The power of written word: reflection reduces errors of omission.
Citation Text:
Rao A, Heidemann LA, Hartley S, et al. The power of written word: reflection reduces errors of omission. Clin Teach. 2024;21(1):e13630. doi:10.1111/tct.13630.
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psnet.ahrq.gov/issue/augmenting-health-care-failure-modes-and-effects-analysis-simulation
December 18, 2024 - Study
Augmenting health care failure modes and effects analysis with simulation.
Citation Text:
Nielsen DS, Dieckmann P, Mohr M, et al. Augmenting health care failure modes and effects analysis with simulation. Simul Healthc. 2014;9(1):48-55. doi:10.1097/SIH.0b013e3182a3defd.
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psnet.ahrq.gov/issue/diagnostic-reliability-teledermatology-systematic-review-and-meta-analysis
September 23, 2020 - Review
Diagnostic reliability in teledermatology: a systematic review and a meta-analysis.
Citation Text:
Bourkas AN, Barone N, Bourkas MEC, et al. Diagnostic reliability in teledermatology: a systematic review and a meta-analysis. BMJ Open. 2023;13(8):e068207. doi:10.1136/bmjopen-2022-0…
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psnet.ahrq.gov/issue/key-performance-outcomes-patient-safety-curricula-root-cause-analysis-failure-mode-and
July 23, 2010 - Commentary
Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills.
Citation Text:
Fassett WE. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects …
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psnet.ahrq.gov/issue/semi-supervised-classification-patient-safety-event-reports
October 31, 2011 - Study
Semi-supervised classification of patient safety event reports.
Citation Text:
McKnight SD. Semi-supervised classification of patient safety event reports. J Patient Saf. 2012;8(2):60-4. doi:10.1097/PTS.0b013e31824ab987.
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psnet.ahrq.gov/issue/structured-judgement-method-enhance-mortality-case-note-review-development-and-evaluation
May 27, 2011 - Study
A structured judgement method to enhance mortality case note review: development and evaluation.
Citation Text:
Hutchinson A, Coster JE, Cooper KL, et al. A structured judgement method to enhance mortality case note review: development and evaluation. BMJ Qual Saf. 2013;22(12). do…
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psnet.ahrq.gov/issue/patient-safety-ten-unmistakable-progress-troubling-gaps
March 02, 2011 - Commentary
Classic
Patient safety at ten: unmistakable progress, troubling gaps.
Citation Text:
Wachter R. Patient safety at ten: unmistakable progress, troubling gaps. Health Aff (Millwood). 2010;29(1):165-173. doi:10.1377/hlthaff.2009.0785.
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psnet.ahrq.gov/issue/pragmatic-insights-patient-safety-priorities-and-intervention-strategies-ambulatory-settings
January 06, 2018 - Commentary
Pragmatic insights on patient safety priorities and intervention strategies in ambulatory settings.
Citation Text:
Sarkar U, McDonald KM, Motala A, et al. Pragmatic Insights on Patient Safety Priorities and Intervention Strategies in Ambulatory Settings. Jt Comm J Qual Patient…
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psnet.ahrq.gov/issue/reducing-readmission-academic-medical-center-results-pharmacy-facilitated-discharge
August 04, 2021 - Study
Reducing readmission at an academic medical center: results of a pharmacy-facilitated discharge counseling and medication reconciliation program.
Citation Text:
Zemaitis CT, Morris G, Cabie M, et al. Reducing Readmission at an Academic Medical Center: Results of a Pharmacy-Facilita…
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psnet.ahrq.gov/issue/broken-hospital-windows-debating-theory-spreading-disorder-and-its-application-healthcare
October 26, 2022 - Commentary
'Broken hospital windows': debating the theory of spreading disorder and its application to healthcare organizations.
Citation Text:
Churruca K, Ellis LA, Braithwaite J. 'Broken hospital windows': debating the theory of spreading disorder and its application to healthcare orga…
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psnet.ahrq.gov/issue/implementing-error-disclosure-coaching-model-multicenter-case-study
May 11, 2016 - Study
Implementing an error disclosure coaching model: a multicenter case study.
Citation Text:
White AA, Brock DM, McCotter PI, et al. Implementing an error disclosure coaching model: A multicenter case study. J Healthc Risk Manag. 2017;36(3):34-45. doi:10.1002/jhrm.21260.
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psnet.ahrq.gov/issue/improved-incident-reporting-following-implementation-standardized-emergency-department-peer
September 10, 2014 - Study
Improved incident reporting following the implementation of a standardized emergency department peer review process.
Citation Text:
Reznek MA, Barton BA. Improved incident reporting following the implementation of a standardized emergency department peer review process. Int J Qual …