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psnet.ahrq.gov/issue/analysis-electronic-health-record-related-patient-safety-incidents
August 19, 2020 - Study
An analysis of electronic health record–related patient safety incidents.
Citation Text:
Palojoki S, Mäkelä M, Lehtonen L, et al. An analysis of electronic health record-related patient safety incidents. Health Informatics J. 2017;23(2):134-145. doi:10.1177/1460458216631072.
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psnet.ahrq.gov/issue/modifying-head-nurse-messages-during-daily-conversations-leverage-safety-climate-improvement
August 26, 2011 - Study
Modifying head nurse messages during daily conversations as leverage for safety climate improvement: a randomised field experiment.
Citation Text:
Zohar D, Werber YT, Marom R, et al. Modifying head nurse messages during daily conversations as leverage for safety climate improvement…
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psnet.ahrq.gov/issue/implementation-emergency-department-sign-out-checklist-improves-transfer-information-shift
October 30, 2019 - Study
Implementation of an emergency department sign-out checklist improves transfer of information at shift change.
Citation Text:
Dubosh NM, Carney D, Fisher J, et al. Implementation of an emergency department sign-out checklist improves transfer of information at shift change. J Emerg…
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psnet.ahrq.gov/issue/effect-checklist-quality-patient-handover-operating-room-intensive-care-unit-randomized
April 03, 2013 - Study
The effect of a checklist on the quality of patient handover from the operating room to the intensive care unit: a randomized controlled trial.
Citation Text:
Salzwedel C, Mai V, Punke MA, et al. The effect of a checklist on the quality of patient handover from the operating room t…
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psnet.ahrq.gov/issue/communication-failure-operating-room
February 25, 2009 - Study
Communication failure in the operating room.
Citation Text:
Halverson AL, Casey JT, Andersson J, et al. Communication failure in the operating room. Surgery. 2011;149(3):305-310. doi:10.1016/j.surg.2010.07.051.
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psnet.ahrq.gov/issue/systematic-literature-review-and-narrative-synthesis-risks-medical-discharge-letters-patients
June 26, 2019 - Review
Emerging Classic
A systematic literature review and narrative synthesis on the risks of medical discharge letters for patients' safety.
Citation Text:
Schwarz CM, Hoffmann M, Schwarz P, et al. A systematic literature review and narrative synthesis on the …
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psnet.ahrq.gov/issue/handoffs-causing-patient-harm-survey-medical-and-surgical-house-staff
July 10, 2008 - Study
Handoffs causing patient harm: a survey of medical and surgical house staff.
Citation Text:
Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34(10):563-70.
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psnet.ahrq.gov/issue/structuring-patient-and-family-involvement-medical-error-event-disclosure-and-analysis
September 01, 2018 - Study
Structuring patient and family involvement in medical error event disclosure and analysis.
Citation Text:
Etchegaray J, Ottosen M, Burress L, et al. Structuring patient and family involvement in medical error event disclosure and analysis. Health Aff (Millwood). 2014;33(1):46-52. d…
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psnet.ahrq.gov/issue/unit-based-care-teams-and-frequency-and-quality-physician-nurse-communications
November 16, 2022 - Study
Unit-based care teams and the frequency and quality of physician–nurse communications.
Citation Text:
Gordon M, Melvin P, Graham DA, et al. Unit-based care teams and the frequency and quality of physician-nurse communications. Arch Pediatr Adolesc Med. 2011;165(5):424-8. doi:10.100…
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psnet.ahrq.gov/issue/recruitment-hospitals-safety-climate-study-facilitators-and-barriers
June 16, 2011 - Study
Recruitment of hospitals for a safety climate study: facilitators and barriers.
Citation Text:
Rosen AK, Gaba DM, Meterko M, et al. Recruitment of hospitals for a safety climate study: facilitators and barriers. Jt Comm J Qual Patient Saf. 2008;34(5):275-84.
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psnet.ahrq.gov/issue/relationship-emotional-climate-work-and-threat-patient-outcome-high-volume-thoracic-surgery
July 05, 2013 - Study
The relationship of the emotional climate of work and threat to patient outcome in a high-volume thoracic surgery operating room team.
Citation Text:
Nurok M, Evans LA, Lipsitz S, et al. The relationship of the emotional climate of work and threat to patient outcome in a high-vo…
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psnet.ahrq.gov/issue/patient-and-visitor-aggression-healthcare-survey-exploring-organisational-safety-culture-and
September 20, 2011 - Study
Patient and visitor aggression in healthcare: a survey exploring organisational safety culture and team efficacy.
Citation Text:
Heckemann B, Hahn S, Halfens RJG, et al. Patient and visitor aggression in healthcare: A survey exploring organisational safety culture and team efficacy…
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psnet.ahrq.gov/issue/unexpected-death-patient-during-treatment-multiple-medications-tomah-va-medical-center-tomah
October 12, 2022 - Government Resource
Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin.
Citation Text:
Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin. Washington, DC: VA …
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psnet.ahrq.gov/issue/new-evidence-based-estimate-patient-harms-associated-hospital-care
October 19, 2022 - Review
A new, evidence-based estimate of patient harms associated with hospital care.
Citation Text:
James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122-128. doi:10.1097/PTS.0b013e3182948a69.
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psnet.ahrq.gov/issue/effects-racial-bias-pulse-oximetry-children-and-how-address-algorithmic-bias-clinical
May 08, 2017 - Commentary
Effects of racial bias in pulse oximetry on children and how to address algorithmic bias in clinical medicine.
Citation Text:
Gray KD, Subramaniam HL, Huang ES. Effects of racial bias in pulse oximetry on children and how to address algorithmic bias in clinical medicine. JAMA …
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psnet.ahrq.gov/issue/unintended-consequences-computerized-provider-order-entry-findings-mixed-methods-exploration
May 27, 2011 - Study
The unintended consequences of computerized provider order entry: findings from a mixed methods exploration.
Citation Text:
Ash JS, Sittig DF, Dykstra RH, et al. The unintended consequences of computerized provider order entry: Findings from a mixed methods exploration. Int J Med…
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psnet.ahrq.gov/issue/usability-and-safety-analysis-electronic-health-records-multi-center-study
October 13, 2018 - Study
Emerging Classic
A usability and safety analysis of electronic health records: a multi-center study.
Citation Text:
Ratwani RM, Savage E, Will A, et al. A usability and safety analysis of electronic health records: a multi-center study. J Am Med Inform Ass…
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psnet.ahrq.gov/issue/measuring-patient-safety-climate-review-surveys
June 14, 2011 - Review
Classic
Measuring patient safety climate: a review of surveys.
Citation Text:
Colla JB, Bracken AC, Kinney LM, et al. Measuring patient safety climate: a review of surveys. Qual Saf Health Care. 2005;14(5):364-6.
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psnet.ahrq.gov/issue/preliminary-development-and-testing-global-trigger-tool-detect-error-and-patient-harm-primary
January 19, 2011 - Study
The preliminary development and testing of a global trigger tool to detect error and patient harm in primary-care records.
Citation Text:
de Wet C, Bowie P. The preliminary development and testing of a global trigger tool to detect error and patient harm in primary-care records. …
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psnet.ahrq.gov/issue/identifying-errors-and-safety-considerations-patients-undergoing-thrombolysis-acute-ischemic
February 09, 2022 - Study
Identifying errors and safety considerations in patients undergoing thrombolysis for acute ischemic stroke.
Citation Text:
Dancsecs KA, Nestor M, Bailey A, et al. Identifying errors and safety considerations in patients undergoing thrombolysis for acute ischemic stroke. Am J Emerg …