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October 27, 2021 - Malnutrition in Hospitalized Adults: A Systematic Review.
October 27, 2021
Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality;
October 2021. AHRQ Publication No. 21(22)-EHC035.
https://psnet.ahrq.gov/issue/malnutrition-hospitalized-adults-systematic-review
Patien…
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September 16, 2009 - Examination of how a survey can spur culture changes
using a quality improvement approach: a region-wide
approach to determining a patient safety culture.
September 16, 2009
Pringle J, Weber RJ, Rice K, et al. Examination of how a survey can spur culture changes using a quality
improvement approach: a region-wide …
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August 24, 2016 - 5 cataract surgeries, 5 people blinded: what went wrong?
August 24, 2016
Kowalczyk L. Boston Globe. August 14, 2016.
https://psnet.ahrq.gov/issue/5-cataract-surgeries-5-people-blinded-what-went-wrong
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on
a series o…
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December 16, 2021 - New AHRQ SOPS® Workplace Safety Supplemental Items
for Hospitals.
November 24, 2021
Rockville, MD: Agency for Healthcare Research and Quality; December 16, 2021.
https://psnet.ahrq.gov/issue/new-ahrq-sopsr-workplace-safety-supplemental-items-hospitals
The release of the Workplace Safety supplemental items for…
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August 31, 2022 - Acute clinical deterioration and consumer escalation: the
understanding and perceptions of hospital staff.
August 31, 2022
Thiele L, Flabouris A, Thompson C. Acute clinical deterioration and consumer escalation: the
understanding and perceptions of hospital staff. PLoS ONE. 2022;17(6):e0269921.
doi:10.1371/journal…
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January 02, 2017 - Intimidation: practitioners speak up about this unresolved
problem.
January 2, 2017
Smetzer JL, Cohen MR. Intimidation: Practitioners Speak Up About This Unresolved Problem. Jt Comm J
Qual Patient Saf. 2016;31(10):594-599. doi:10.1016/s1553-7250(05)31077-4.
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December 16, 2015 - Harms from discharge to primary care: mixed methods
analysis of incident reports.
December 16, 2015
Williams H, Edwards A, Hibbert P, et al. Harms from discharge to primary care: mixed methods analysis of
incident reports. Br J Gen Pract. 2015;65(641):e829-e837. doi:10.3399/bjgp15X687877.
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February 23, 2022 - Improving responses to safety incidents: we need to talk
about justice.
February 23, 2022
Cribb A, O'Hara JK, Waring J. Improving responses to safety incidents: we need to talk about justice. BMJ
Qual Saf. 2022;31(4):327-330. doi:10.1136/bmjqs-2021-014333.
https://psnet.ahrq.gov/issue/improving-responses-safety-in…
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October 19, 2022 - Resident and nurse perspectives on the use of secure
text messaging systems.
October 19, 2022
Aziz S, Barber J, Singh A, et al. Resident and nurse perspectives on the use of secure text messaging
systems. J Hosp Med. 2022;17(11):880-887. doi:10.1002/jhm.12953.
https://psnet.ahrq.gov/issue/resident-and-nurse-perspe…
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psnet.ahrq.gov/node/40177/psn-pdf
June 08, 2011 - Learning from disasters to improve patient safety:
applying the generic disaster pathway to health system
errors.
June 8, 2011
Travaglia J, Hughes C, Braithwaite J. Learning from disasters to improve patient safety: applying the
generic disaster pathway to health system errors. BMJ Qual Saf. 2011;20(1):1-8.
doi:1…
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December 15, 2014 - Implementation of an emergency department sign-out
checklist improves transfer of information at shift change.
December 15, 2014
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 Med. 2014;47(5):580-5.
doi:10…
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September 06, 2023 - Weight estimation for drug dose calculations in the
prehospital setting - a systematic review.
September 6, 2023
Wells M, Henry B, Goldstein L. Weight estimation for drug dose calculations in the prehospital setting - a
systematic review. Prehosp Disaster Med. 2023;38(4):471-484. doi:10.1017/s1049023x23006027.
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April 30, 2019 - ISMP Gap Analysis Tool (GAT) for Safe IV Push
Medication Practices.
April 30, 2019
Horsham, PA: Institute for Safe Medication Practices; 2018.
https://psnet.ahrq.gov/issue/ismp-gap-analysis-tool-gat-safe-iv-push-medication-practices
Standardized practices have not been uniformly adopted to support safe IV medicati…
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October 04, 2017 - Managing the Costs of Clinical Negligence in Trusts.
October 4, 2017
Comptroller and Auditor General, Department of Health; London, UK: National Audit Office; 2017. ISBN:
9781786041395.
https://psnet.ahrq.gov/issue/managing-costs-clinical-negligence-trusts
Applying evidence generated from complaints submitted to h…
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May 29, 2023 - Ambulatory Surgery Center Survey on Patient Safety
Culture.
May 29, 2023
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
https://psnet.ahrq.gov/issue/ambulatory-surgery-center-survey-patient-safety-culture
Ambulatory surgery centers (ASCs) are increasingly being used to provide surgical ca…
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March 24, 2021 - Well-Being Playbook 2.0. A COVID-19 Resource for
Hospital and Health System Leaders.
March 24, 2021
AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.
https://psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders
Human factors enginee…
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September 02, 2015 - Health Literacy: Past, Present, and Future: Workshop
Summary.
September 2, 2015
Alper J; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of
Medicine. Washington, DC: National Academies of Sciences, Engineering, and Medicine; 2015. ISBN:
9780309371544.
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May 27, 2009 - Prevention of retained surgical sponges: a decision-
analytic model predicting relative cost-effectiveness.
May 27, 2009
Regenbogen SE, Greenberg CC, Resch SC, et al. Prevention of retained surgical sponges: a decision-
analytic model predicting relative cost-effectiveness. Surgery. 2009;145(5):527-35.
doi:10.1016…
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May 28, 2014 - Exploring perinatal shift-to-shift handover communication
and process: an observational study.
May 28, 2014
Poot EP, de Bruijne M, Wouters MGAJ, et al. Exploring perinatal shift-to-shift handover communication and
process: an observational study. J Eval Clin Pract. 2014;20(2):166-75. doi:10.1111/jep.12103.
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April 08, 2011 - Team training in the neonatal resuscitation program for
interns: teamwork and quality of resuscitations.
April 8, 2011
Thomas EJ, Williams AL, Reichman EF, et al. Team training in the neonatal resuscitation program for
interns: teamwork and quality of resuscitations. Pediatrics. 2010;125(3):539-546. doi:10.1542/ped…