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psnet.ahrq.gov/issue/using-simulation-improve-systems-based-practices
January 22, 2016 - Review
Using simulation to improve systems-based practices.
Citation Text:
Gardner AK, Johnston MJ, Korndorffer JR, et al. Using Simulation to Improve Systems-Based Practices. Jt Comm J Qual Patient Saf. 2017;43(9):484-491. doi:10.1016/j.jcjq.2017.05.006.
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psnet.ahrq.gov/issue/use-who-surgical-safety-checklist-trauma-and-orthopaedic-patients
August 30, 2017 - Study
Use of the WHO surgical safety checklist in trauma and orthopaedic patients.
Citation Text:
Sewell M, Adebibe M, Jayakumar P, et al. Use of the WHO surgical safety checklist in trauma and orthopaedic patients. Int Orthop. 2011;35(6):897-901. doi:10.1007/s00264-010-1112-7.
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psnet.ahrq.gov/issue/staying-silent-about-safety-issues-conceptualizing-and-measuring-safety-silence-motives
August 28, 2019 - Study
Staying silent about safety issues: conceptualizing and measuring safety silence motives.
Citation Text:
Manapragada A, Bruk-Lee V. Staying silent about safety issues: Conceptualizing and measuring safety silence motives. Accid Anal Prev. 2016;91:144-56. doi:10.1016/j.aap.2016.02.0…
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psnet.ahrq.gov/issue/research-practice-factors-affecting-implementation-prospective-targeted-injury-detection
August 04, 2021 - Study
From research to practice: factors affecting implementation of prospective targeted injury-detection systems.
Citation Text:
Sorensen A, Harrison MI, Kane HL, et al. From research to practice: factors affecting implementation of prospective targeted injury-detection systems. BMJ …
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psnet.ahrq.gov/issue/multidisciplinary-hospital-teams-improve-patient-outcomes-review
February 03, 2011 - Review
Multidisciplinary in-hospital teams improve patient outcomes: a review.
Citation Text:
Epstein NE. Multidisciplinary in-hospital teams improve patient outcomes: A review. Surg Neurol Int. 2014;5(Suppl 7):S295-303. doi:10.4103/2152-7806.139612.
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psnet.ahrq.gov/issue/applied-use-safety-event-occurrence-control-charts-harm-and-non-harm-events-case-study
October 23, 2024 - Commentary
Applied use of safety event occurrence control charts of harm and non-harm events: a case study.
Citation Text:
Robinson SN, Neyens DM, Diller T. Applied Use of Safety Event Occurrence Control Charts of Harm and Non-Harm Events: A Case Study. Am J Med Qual. 2017;32(3):285-291.…
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psnet.ahrq.gov/issue/lessons-unexpected-increased-mortality-after-implementation-commercially-sold-computerized
April 29, 2018 - Commentary
Lessons from "unexpected increased mortality after implementation of a commercially sold computerized physician order entry system."
Citation Text:
Sittig DF, Ash JS, Zhang J, et al. Lessons from "Unexpected increased mortality after implementation of a commercially sold com…
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psnet.ahrq.gov/issue/ascension-healths-demonstration-full-disclosure-protocol-unexpected-events-during-labor-and
January 22, 2017 - Study
Ascension Health's demonstration of full disclosure protocol for unexpected events during labor and delivery shows promise.
Citation Text:
Hendrich A, McCoy CK, Gale J, et al. Ascension health's demonstration of full disclosure protocol for unexpected events during labor and deliv…
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psnet.ahrq.gov/issue/use-patient-pictures-and-verification-screens-reduce-computerized-provider-order-entry-errors
November 16, 2022 - Study
The use of patient pictures and verification screens to reduce computerized provider order entry errors.
Citation Text:
Hyman D, Laire M, Redmond D, et al. The use of patient pictures and verification screens to reduce computerized provider order entry errors. Pediatrics. 2012;130(…
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psnet.ahrq.gov/issue/what-we-know-about-designing-effective-improvement-intervention-too-often-fail-put-practice
September 06, 2017 - Commentary
What we know about designing an effective improvement intervention (but too often fail to put into practice).
Citation Text:
Marshall M, de Silva D, Cruickshank L, et al. What we know about designing an effective improvement intervention (but too often fail to put into practic…
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psnet.ahrq.gov/issue/medical-malpractice-reflected-forensic-evaluation-4450-autopsies
September 02, 2009 - Study
Medical malpractice as reflected by the forensic evaluation of 4450 autopsies.
Citation Text:
Madea B, Preuss J. Medical malpractice as reflected by the forensic evaluation of 4450 autopsies. Forensic Sci Int. 2009;190(1-3):58-66. doi:10.1016/j.forsciint.2009.05.013.
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psnet.ahrq.gov/issue/patterns-errors-contributing-trauma-mortality-lessons-learned-2594-deaths
March 24, 2021 - Study
Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths.
Citation Text:
Gruen RL, Jurkovich GJ, McIntyre LK, et al. Patterns of Errors Contributing to Trauma Mortality. Transactions of the .. Meeting of the American Surgical Association. 2006;124. d…
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psnet.ahrq.gov/issue/social-dimensions-safety-incident-reporting-maternity-care-influence-working-relationships
September 18, 2024 - Study
The social dimensions of safety incident reporting in maternity care: the influence of working relationships and group processes.
Citation Text:
Lindsay P, Sandall J, Humphrey C. The social dimensions of safety incident reporting in maternity care: the influence of working relati…
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psnet.ahrq.gov/issue/team-climate-inventory-application-hospital-teams-and-methodological-considerations
December 31, 2012 - Study
The Team Climate Inventory: application in hospital teams and methodological considerations.
Citation Text:
Ouwens M, Hulscher M, Akkermans R, et al. The Team Climate Inventory: application in hospital teams and methodological considerations. Qual Saf Health Care. 2008;17(4):275-…
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psnet.ahrq.gov/issue/current-pulse-can-production-system-reduce-medical-errors-health-care
September 09, 2011 - Commentary
Current pulse: can a production system reduce medical errors in health care?
Citation Text:
Printezis A, Gopalakrishnan M. Current pulse: can a production system reduce medical errors in health care? Qual Manag Health Care. 2007;16(3):226-238.
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psnet.ahrq.gov/node/50689/psn-pdf
November 20, 2019 - States Targeting Reduction in Infections via Engagement
(STRIVE).
November 20, 2019
Ann Intern Med. 2019;171(7_Suppl):s1-s82.
https://psnet.ahrq.gov/issue/states-targeting-reduction-infections-engagement-strive
The States Targeting Reduction in Infections via Engagement (STRIVE) initiative was 3-year hospital-
ba…
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psnet.ahrq.gov/issue/guidance-patient-safety-ophthalmology-royal-college-ophthalmologists
November 12, 2014 - Review
Guidance on patient safety in ophthalmology from the Royal College of Ophthalmologists.
Citation Text:
Kelly SP, Ophthalmologists RC of. Guidance on patient safety in ophthalmology from the Royal College of Ophthalmologists. Eye (Lond). 2009;23(12):2143-51. doi:10.1038/eye.2009.…
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psnet.ahrq.gov/issue/accuracy-adverse-drug-event-reports-collected-using-automated-dispensing-system
April 06, 2022 - Study
Accuracy of adverse-drug-event reports collected using an automated dispensing system.
Citation Text:
Romero A, Malone DC. Accuracy of adverse-drug-event reports collected using an automated dispensing system. Am J Health Syst Pharm. 2005;62(13):1375-80.
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psnet.ahrq.gov/issue/distraction-and-interruption-anaesthetic-practice
May 18, 2022 - Study
Distraction and interruption in anaesthetic practice.
Citation Text:
Campbell G, Arfanis K, Smith AF. Distraction and interruption in anaesthetic practice. Br J Anaesth. 2012;109(5):707-715. doi:10.1093/bja/aes219.
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psnet.ahrq.gov/issue/how-well-do-we-communicate-comparison-intraoperative-diagnoses-listed-pathology-reports-and
May 29, 2019 - Study
How well do we communicate? A comparison of intraoperative diagnoses listed in pathology reports and operative notes.
Citation Text:
Talmon G, Horn A, Wedel W, et al. How well do we communicate?: a comparison of intraoperative diagnoses listed in pathology reports and operative no…