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psnet.ahrq.gov/issue/case-study-preventing-surgical-complications-baystate-medical-center
May 27, 2011 - Commentary
Case study: preventing surgical complications at Baystate Medical Center.
Citation Text:
Fitzgerald J, Kanter G, Benjamin EM. Case Study: Preventing Surgical Complications at Baystate Medical Center. The Joint Commission Journal on Quality and Patient Safety. 2016;33(11). doi:…
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psnet.ahrq.gov/issue/hand-communications
January 04, 2017 - Multi-use Website
Hand-off Communications.
Citation Text:
DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system.
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psnet.ahrq.gov/issue/mastering-improvement-science-skills-new-era-quality-and-safety-veterans-affairs-national
December 12, 2012 - Commentary
Mastering improvement science skills in the new era of quality and safety: the Veterans Affairs National Quality Scholars Program.
Citation Text:
Estrada CA, Dolansky MA, Singh MK, et al. Mastering improvement science skills in the new era of quality and safety: the Veterans…
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psnet.ahrq.gov/issue/improved-prophylaxis-and-decreased-rates-preventable-harm-use-mandatory-computerized-clinical
June 21, 2016 - Study
Improved prophylaxis and decreased rates of preventable harm with the use of a mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma.
Citation Text:
Haut ER, Lau BD, Kraenzlin FS, et al. Improved prophylaxis and decreased rates o…
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psnet.ahrq.gov/issue/how-safety-compromised-when-hospital-equipment-poor-fit-patients-who-are-obese
October 07, 2020 - Study
How safety is compromised when hospital equipment is a poor fit for patients who are obese.
Citation Text:
Kukielka E. How safety is compromised when hospital equipment is a poor fit for patients who are obese. Patient Saf J. 2020;2(1):48-56. doi:10.33940/data/2020.3.4.
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psnet.ahrq.gov/issue/using-interactive-voice-response-system-improve-patient-safety-following-hospital-discharge
February 01, 2017 - Study
Using an interactive voice response system to improve patient safety following hospital discharge.
Citation Text:
Forster AJ, van Walraven C. Using an interactive voice response system to improve patient safety following hospital discharge. J Eval Clin Pract. 2007;13(3):346-51.
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psnet.ahrq.gov/issue/handing-over-patient-care-it-just-old-broken-telephone-game
March 01, 2017 - Study
Handing over patient care: is it just the old broken telephone game?
Citation Text:
Zendejas B, Ali SM, Huebner M, et al. Handing over patient care: is it just the old broken telephone game? J Surg Educ. 2011;68(6):465-71. doi:10.1016/j.jsurg.2011.05.011.
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psnet.ahrq.gov/issue/rapid-response-teams-and-continuous-quality-improvement
April 05, 2023 - Study
Rapid response teams and continuous quality improvement.
Citation Text:
Rapid response teams and continuous quality improvement. Dailey MS, Durkin S, Gulczynski B, et al. Patient Saf Qual Healthc. Nov/Dec 2009;6:28-31.
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psnet.ahrq.gov/issue/patient-safety-and-leadership-do-you-walk-walk
November 04, 2020 - Commentary
Patient safety and leadership: do you walk the walk?
Citation Text:
Jarrett MP. Patient Safety and Leadership: Do You Walk the Walk? J Healthc Manag. 2017;62(2):88-92. doi:10.1097/JHM-D-17-00005.
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psnet.ahrq.gov/issue/description-inpatient-medication-management-using-cognitive-work-analysis
October 19, 2022 - Study
Description of inpatient medication management using cognitive work analysis.
Citation Text:
Pingenot AA, Shanteau J, Sengstacke LTCDN. Description of inpatient medication management using cognitive work analysis. Comput Inform Nurs. 2009;27(6):379-92. doi:10.1097/NCN.0b013e3181b…
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psnet.ahrq.gov/issue/architecture-safety-emerging-priority-improving-patient-safety
June 09, 2011 - Review
The architecture of safety: an emerging priority for improving patient safety.
Citation Text:
Joseph A, Henriksen K, Malone E. The Architecture Of Safety: An Emerging Priority For Improving Patient Safety. Health Aff (Millwood). 2018;37(11):1884-1891. doi:10.1377/hlthaff.2018.0643…
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psnet.ahrq.gov/issue/exploring-causes-adverse-events-hospitals-and-potential-prevention-strategies
February 20, 2013 - Study
Exploring the causes of adverse events in hospitals and potential prevention strategies.
Citation Text:
Smits M, Zegers M, Groenewegen PP, et al. Exploring the causes of adverse events in hospitals and potential prevention strategies. BMJ Qual Saf. 2010;19(5). doi:10.1136/qshc.20…
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psnet.ahrq.gov/issue/national-reporting-and-learning-system-research-and-development
April 06, 2016 - Book/Report
National Reporting and Learning System Research and Development.
Citation Text:
National Reporting and Learning System Research and Development. Mayer E, Flott K, Callahan R, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research Centre; 2016.
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psnet.ahrq.gov/issue/annotated-bibliography-understanding-ambulatory-care-practices-context-patient-safety-and
March 02, 2010 - Commentary
Annotated bibliography: an update to: "Understanding ambulatory care practices in the context of patient safety and quality improvement."
Citation Text:
Kumar PR, Nash DB. Annotated Bibliography: An Update to “Understanding Ambulatory Care Practices in the Context of Patient S…
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psnet.ahrq.gov/issue/critical-role-surgeon-anesthesiologist-relationship-patient-safety
November 11, 2020 - Commentary
Critical role of the surgeon–anesthesiologist relationship for patient safety.
Citation Text:
Cooper JB. Critical Role of the Surgeon-Anesthesiologist Relationship for Patient Safety. Anesthesiology. 2018;129(3):402-405. doi:10.1097/ALN.0000000000002324.
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psnet.ahrq.gov/issue/strategic-work-arounds-accommodate-new-technology-case-smart-pumps-hospital-care
July 14, 2010 - Study
Strategic work-arounds to accommodate new technology: the case of smart pumps in hospital care.
Citation Text:
McAlearney AS, Vrontos J, Schneider PJ, et al. Strategic Work-Arounds to Accommodate New Technology. J Patient Saf. 2008;3(2). doi:10.1097/01.jps.0000242987.93789.63.
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psnet.ahrq.gov/issue/problem-5-whys
July 19, 2023 - Commentary
The problem with the '5 whys.'
Citation Text:
Card AJ. The problem with '5 whys'. BMJ Qual Saf. 2017;26(8):671-677. doi:10.1136/bmjqs-2016-005849.
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psnet.ahrq.gov/issue/developing-and-evaluating-trigger-response-system
August 29, 2018 - Study
Developing and evaluating a trigger response system.
Citation Text:
Cherry K, Martinek J, Esleck S, et al. Developing and Evaluating a Trigger Response System. The Joint Commission Journal on Quality and Patient Safety. 2016;35(6). doi:10.1016/s1553-7250(09)35047-3.
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psnet.ahrq.gov/issue/physicians-diagnostic-accuracy-confidence-and-resource-requests-vignette-study
May 29, 2015 - Study
Physicians' diagnostic accuracy, confidence, and resource requests: a vignette study.
Citation Text:
Meyer AND, Payne VL, Meeks DW, et al. Physicians' diagnostic accuracy, confidence, and resource requests: a vignette study. JAMA Intern Med. 2013;173(21):1952-1958. doi:10.1001/jama…
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psnet.ahrq.gov/issue/improving-patient-safety-through-simulation-training-anesthesiology-where-are-we
October 13, 2018 - Review
Improving patient safety through simulation training in anesthesiology: where are we?
Citation Text:
Green M, Tariq R, Green P. Improving Patient Safety through Simulation Training in Anesthesiology: Where Are We? Anesthesiol Res Pract. 2016;2016:4237523. doi:10.1155/2016/4237523.…