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psnet.ahrq.gov/issue/application-iv-medication-harm-index-assess-nature-harm-averted-smart-infusion-safety-systems
January 23, 2017 - Study
Application of the IV Medication Harm Index to assess the nature of harm averted by "smart" infusion safety systems.
Citation Text:
Williams CK, Maddox RR, Heape E, et al. Application of the IV Medication Harm Index to Assess the Nature of Harm Averted by "Smart" Infusion Safety …
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psnet.ahrq.gov/issue/prevented-harm-and-cost-avoidance-pharmacist-intervention-while-utilizing-discharge
October 19, 2022 - Study
Prevented harm and cost avoidance with pharmacist intervention while utilizing a discharge medication reconciliation tool.
Citation Text:
Hoffman AM, Walls JL, Prusch A, et al. Prevented harm and cost avoidance with pharmacist intervention while utilizing a discharge medication rec…
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psnet.ahrq.gov/issue/use-second-victim-experience-and-support-tool-svest-assess-impact-departmental-peer-support
December 23, 2020 - Study
Use of the Second Victim Experience and Support Tool (SVEST) to assess the impact of a departmental peer support program on anesthesia professionals' second victim experiences (SVEs) and perceptions of support two years after implementation.
Citation Text:
Use of the Second Victim …
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psnet.ahrq.gov/issue/impact-leadership-walkarounds-operational-cultural-and-clinical-outcomes-systematic-review
October 12, 2022 - Review
Impact of leadership walkarounds on operational, cultural and clinical outcomes: a systematic review.
Citation Text:
Foster M, MHA BS, Mazur L. Impact of leadership walkarounds on operational, cultural and clinical outcomes: a systematic review. BMJ Open Qual. 2023;12(4):e002284. …
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psnet.ahrq.gov/issue/development-and-evaluation-observational-tool-assessing-surgical-flow-disruptions-and-their
June 17, 2009 - Study
Development and evaluation of an observational tool for assessing surgical flow disruptions and their impact on surgical performance.
Citation Text:
Parker SEH, Laviana AA, Wadhera RK, et al. Development and evaluation of an observational tool for assessing surgical flow disruption…
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psnet.ahrq.gov/issue/medication-appropriateness-vulnerable-older-adults-healthy-skepticism-appropriate
October 04, 2023 - Review
Medication appropriateness in vulnerable older adults: healthy skepticism of appropriate polypharmacy.
Citation Text:
Fried TR, Mecca MC. Medication Appropriateness in Vulnerable Older Adults: Healthy Skepticism of Appropriate Polypharmacy. J Am Geriatr Soc. 2019;67(6):1123-1127. …
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psnet.ahrq.gov/issue/assessing-distractors-and-teamwork-during-surgery-developing-event-based-method-direct
February 19, 2020 - Study
Assessing distractors and teamwork during surgery: developing an event-based method for direct observation.
Citation Text:
Seelandt JC, Tschan F, Keller S, et al. Assessing distractors and teamwork during surgery: developing an event-based method for direct observation. BMJ Qual Sa…
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psnet.ahrq.gov/issue/pursuing-patient-safety-intersection-design-systems-engineering-and-health-care-delivery
June 25, 2018 - Commentary
Pursuing patient safety at the intersection of design, systems engineering, and health care delivery research: an ongoing assessment.
Citation Text:
Henriksen K, Rodrick D, Grace EN, et al. Pursuing Patient Safety at the Intersection of Design, Systems Engineering, and Health …
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psnet.ahrq.gov/issue/ageing-surgeon-qualitative-study-expert-opinions-assuring-performance-and-supporting-safe
May 05, 2021 - Study
The ageing surgeon: a qualitative study of expert opinions on assuring performance and supporting safe career transitions among older surgeons.
Citation Text:
Sherwood R, Bismark M. The ageing surgeon: a qualitative study of expert opinions on assuring performance and supporting sa…
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psnet.ahrq.gov/issue/safe-day-call-reducing-silos-health-care-through-frontline-risk-assessment
May 25, 2016 - Commentary
The safe day call: reducing silos in health care through frontline risk assessment.
Citation Text:
Paterson C, Miller K, Benden M, et al. The Safe Day Call: Reducing Silos in Health Care Through Frontline Risk Assessment. Jt Comm J Qual Patient Saf. 2014;40(10):476-481.
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psnet.ahrq.gov/issue/principles-practice-embedding-clinical-reasoning-longitudinal-curriculum-theme-medical-school
September 09, 2020 - Commentary
From principles to practice: embedding clinical reasoning as a longitudinal curriculum theme in a medical school programme.
Citation Text:
Singh M, Collins L, Farrington R, et al. From principles to practice: embedding clinical reasoning as a longitudinal curriculum theme in a…
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psnet.ahrq.gov/issue/adverse-events-detected-clinical-surveillance-obstetric-service
September 11, 2009 - Study
Adverse events detected by clinical surveillance on an obstetric service.
Citation Text:
Forster AJ, Fung I, Caughey S, et al. Adverse events detected by clinical surveillance on an obstetric service. Obstet Gynecol. 2006;108(5):1073-83.
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psnet.ahrq.gov/issue/hospital-quality-review-spending-and-patient-safety-longitudinal-analysis-using-instrumental
December 21, 2022 - Study
Hospital quality-review spending and patient safety: a longitudinal analysis using instrumental variables.
Citation Text:
Dynan L, Smith RB. Hospital quality-review spending and patient safety: a longitudinal analysis using instrumental variables. Health Serv Outcomes Res Methodol.…
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psnet.ahrq.gov/issue/medication-complexity-medication-number-and-their-relationships-medication-discrepancies
November 16, 2022 - Study
Medication complexity, medication number, and their relationships to medication discrepancies.
Citation Text:
Patel CH, Zimmerman KM, Fonda JR, et al. Medication Complexity, Medication Number, and Their Relationships to Medication Discrepancies. Ann Pharmacother. 2016;50(7):534-40.…
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psnet.ahrq.gov/issue/psych-mnemonic-help-psychiatric-residents-decrease-patient-handoff-communication-errors
November 16, 2022 - Study
PSYCH: a mnemonic to help psychiatric residents decrease patient handoff communication errors.
Citation Text:
Mariano MT, Brooks V, DiGiacomo M. PSYCH: A Mnemonic to Help Psychiatric Residents Decrease Patient Handoff Communication Errors. Jt Comm J Qual Patient Saf. 2016;42(7):316…
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psnet.ahrq.gov/issue/using-objective-structured-clinical-examination-test-adherence-joint-commission-national
September 26, 2012 - Study
Using an objective structured clinical examination to test adherence to Joint Commission National Patient Safety Goal–associated behaviors.
Citation Text:
Pernar LIM, Shaw T, Pozner CN, et al. Using an Objective Structured Clinical Examination to test adherence to Joint Commissio…
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psnet.ahrq.gov/issue/focus-society-cardiovascular-anesthesiologists-initiative-improve-quality-and-safety
January 03, 2017 - Commentary
FOCUS: The Society of Cardiovascular Anesthesiologists' initiative to improve quality and safety in the cardiovascular operating room.
Citation Text:
Barbeito A, Lau WT, Weitzel N, et al. FOCUS: the Society of Cardiovascular Anesthesiologists' initiative to improve quality and…
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psnet.ahrq.gov/issue/potential-collective-intelligence-emergency-medicine
June 12, 2024 - Study
The potential of collective intelligence in emergency medicine.
Citation Text:
Kämmer JE, Hautz WE, Herzog SM, et al. The Potential of Collective Intelligence in Emergency Medicine: Pooling Medical Students' Independent Decisions Improves Diagnostic Performance. Med Decis Making. 2…
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psnet.ahrq.gov/issue/physicians-practice-dispensing-medicines-qualitative-study
November 16, 2022 - Study
Physicians' practice of dispensing medicines: a qualitative study.
Citation Text:
Darbyshire D, Gordon M, Baker P, et al. Physicians' Practice of Dispensing Medicines: A Qualitative Study. J Patient Saf. 2016;12(2):82-8. doi:10.1097/PTS.0000000000000122.
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psnet.ahrq.gov/issue/feedback-loop-failure-modes-medical-diagnosis-how-biases-can-emerge-and-be-reinforced
November 01, 2023 - Study
Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced.
Citation Text:
Aikens RC, Chen JH, Baiocchi M, et al. Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. Med Decis Making. 2024;44(5):481-496. doi:10.1…