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From reporting to improving: how root cause analysis in teams shape patient safety culture. | PSNet

psnet.ahrq.gov/issue/reporting-improving-how-root-cause-analysis-teams-shape-patient-safety-culture

July 31, 2024 - Study From reporting to improving: how root cause analysis in teams shape patient safety culture. Citation Text: Tsamasiotis C, Fiard G, Bouzat P, et al. From reporting to improving: how root cause analysis in teams shape patient safety culture. Risk Manag Healthc Policy. 2024;17:1847-18…

Developing, implementing, evaluating electronic apparent cause analysis across a health care system. | PSNet

psnet.ahrq.gov/issue/developing-implementing-evaluating-electronic-apparent-cause-analysis-across-health-care

February 07, 2018 - Study Developing, implementing, evaluating electronic apparent cause analysis across a health care system. Citation Text: Oster CA, Woods E, Mumma J, et al. Developing, implementing, evaluating electronic apparent cause analysis across a health care system. Jt Comm J Qual Patient Saf. 2…

Communicating certainty in pathology reports: interpretation differences among staff pathologists, clinicians, and residents in a multicenter study. | PSNet

psnet.ahrq.gov/issue/communicating-certainty-pathology-reports-interpretation-differences-among-staff-pathologists

January 23, 2017 - Study Communicating certainty in pathology reports: interpretation differences among staff pathologists, clinicians, and residents in a multicenter study. Citation Text: Gibson BA, McKinnon E, Bentley RC, et al. Communicating certainty in pathology reports: interpretation differences amo…

Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans. | PSNet

psnet.ahrq.gov/issue/cross-check-qa-quality-assurance-workflow-prevent-missed-diagnoses-alerting-inadvertent

March 04, 2015 - Study Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans. Citation Text: Chekmeyan M, Baccei SJ, Garwood ER. Cross-Check QA: a quality assurance workflow…

Supporting clinicians after adverse events: development of a clinician peer support program. | PSNet

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April 24, 2018 - Study Emerging Classic Supporting clinicians after adverse events: development of a clinician peer support program. Citation Text: Lane MA, Newman BM, Taylor MZ, et al. Supporting Clinicians After Adverse Events: Development of a Clinician Peer Support Program. …

Association of the use of a mandatory prescription drug monitoring program with prescribing practices for patients undergoing elective surgery. | PSNet

psnet.ahrq.gov/issue/association-use-mandatory-prescription-drug-monitoring-program-prescribing-practices-patients

March 01, 2023 - Study Emerging Classic Association of the use of a mandatory prescription drug monitoring program with prescribing practices for patients undergoing elective surgery. Citation Text: Stucke RS, Kelly JL, Mathis KA, et al. Association of the Use of a Mandatory Pre…

High-reliability organisation principles implemented in dentistry. | PSNet

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April 06, 2022 - Commentary High-reliability organisation principles implemented in dentistry. Citation Text: Minyé HM, Benjamin EM. High-reliability organisation principles implemented in dentistry. Br Dent J. 2022;232(12):879-885. doi:10.1038/s41415-022-4354-z. Copy Citation Format: DOI G…

Adverse events after transition from ICU to hospital ward: a multicenter cohort study. | PSNet

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October 13, 2018 - Study Adverse events after transition from ICU to hospital ward: a multicenter cohort study. Citation Text: Sauro KM, Soo A, de Grood C, et al. Adverse Events After Transition From ICU to Hospital Ward: A Multicenter Cohort Study*. Crit Care Med. 2020;48(7):946-953. doi:10.1097/ccm.00000…

'Saying it without words': a qualitative study of oncology staff's experiences with speaking up about safety concerns. | PSNet

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November 05, 2014 - Study 'Saying it without words': a qualitative study of oncology staff's experiences with speaking up about safety concerns. Citation Text: Schwappach DLB, Gehring K. 'Saying it without words': a qualitative study of oncology staff's experiences with speaking up about safety concerns. BM…

Psychometric properties of the perinatal missed care survey and missed care during labor and birth. | PSNet

psnet.ahrq.gov/issue/psychometric-properties-perinatal-missed-care-survey-and-missed-care-during-labor-and-birth

April 12, 2023 - Study Psychometric properties of the perinatal missed care survey and missed care during labor and birth. Citation Text: Lyndon A, Simpson KR, Spetz J, et al. Psychometric properties of the perinatal missed care survey and missed care during labor and birth. Appl Nurs Res. 2022;63:151516…

Perspectives on perioperative team-based morbidity and mortality conferences: a mixed-methods study. | PSNet

psnet.ahrq.gov/issue/perspectives-perioperative-team-based-morbidity-and-mortality-conferences-mixed-methods-study

October 11, 2023 - Study Perspectives on perioperative team-based morbidity and mortality conferences: a mixed-methods study. Citation Text: Samost-Williams A, Rosen R, Cummins E, et al. Perspectives on Perioperative Team-Based Morbidity and Mortality Conferences: A Mixed Methods Study. Jt Comm J Qual Pati…

Approaches for improving continuity of care in medication management: a systematic review. | PSNet

psnet.ahrq.gov/issue/approaches-improving-continuity-care-medication-management-systematic-review

April 13, 2022 - Review Approaches for improving continuity of care in medication management: a systematic review. Citation Text: Spinewine A, Claeys C, Foulon V, et al. Approaches for improving continuity of care in medication management: a systematic review. Int J Qual Health Care. 2013;25(4):403-17. d…

“I made a mistake!”: a narrative analysis of experienced physicians' stories of preventable error. | PSNet

psnet.ahrq.gov/issue/i-made-mistake-narrative-analysis-experienced-physicians-stories-preventable-error

September 26, 2016 - Study “I made a mistake!”: a narrative analysis of experienced physicians' stories of preventable error. Citation Text: Kandasamy S, Vanstone M, Colvin E, et al. “I made a mistake!”: a narrative analysis of experienced physicians' stories of preventable error. J Eval Clin Pract. 2021;27(…

Identification of the barriers and enablers for receiving a speaking up message: a content analysis approach. | PSNet

psnet.ahrq.gov/issue/identification-barriers-and-enablers-receiving-speaking-message-content-analysis-approach

March 29, 2023 - Study Identification of the barriers and enablers for receiving a speaking up message: a content analysis approach. Citation Text: Barlow M, Morse KJ, Watson B, et al. Identification of the barriers and enablers for receiving a speaking up message: a content analysis approach. Adv Simul …

Serious adverse events in pediatric procedural sedation before and after the implementation of a pre-sedation checklist. | PSNet

psnet.ahrq.gov/issue/serious-adverse-events-pediatric-procedural-sedation-and-after-implementation-pre-sedation

February 12, 2020 - Study Serious adverse events in pediatric procedural sedation before and after the implementation of a pre-sedation checklist. Citation Text: Librov S, Shavit I. Serious adverse events in pediatric procedural sedation before and after the implementation of a pre-sedation checklist. J Pai…

Implementing a pre-operative checklist to increase patient safety: a 1-year follow-up of personnel attitudes. | PSNet

psnet.ahrq.gov/issue/implementing-pre-operative-checklist-increase-patient-safety-1-year-follow-personnel

October 19, 2012 - Study Implementing a pre-operative checklist to increase patient safety: a 1-year follow-up of personnel attitudes. Citation Text: Nilsson L, Lindberget O, Gupta A, et al. Implementing a pre-operative checklist to increase patient safety: a 1-year follow-up of personnel attitudes. Acta…

The impact of adding a 2-way video monitoring system on falls and costs for high-risk inpatients. | PSNet

psnet.ahrq.gov/issue/impact-adding-2-way-video-monitoring-system-falls-and-costs-high-risk-inpatients

April 24, 2018 - Study The impact of adding a 2-way video monitoring system on falls and costs for high-risk inpatients. Citation Text: Sosa MA, Soares M, Patel S, et al. The impact of adding a 2-way video monitoring system on falls and costs for high-risk inpatients. J Patient Saf. 2024;20(3):186-191. d…

Modifications to medical emergency team activation criteria and implications for patient safety: a point prevalence study. | PSNet

psnet.ahrq.gov/issue/modifications-medical-emergency-team-activation-criteria-and-implications-patient-safety

July 20, 2022 - Study Modifications to medical emergency team activation criteria and implications for patient safety: a point prevalence study. Citation Text: Sprogis SK, Street M, Currey J, et al. Modifications to medical emergency team activation criteria and implications for patient safety: a point …

A comparison of two distribution methods on response rates to a patient safety questionnaire in nursing homes. | PSNet

psnet.ahrq.gov/issue/comparison-two-distribution-methods-response-rates-patient-safety-questionnaire-nursing-homes

September 14, 2011 - Study A comparison of two distribution methods on response rates to a patient safety questionnaire in nursing homes. Citation Text: Lapane KL, Quilliam BJ, Hughes C. A comparison of two distribution methods on response rates to a patient safety questionnaire in nursing homes. J Am Med …

Improving employee voice about transgressive or disruptive behavior: a case study. | PSNet

psnet.ahrq.gov/issue/improving-employee-voice-about-transgressive-or-disruptive-behavior-case-study

June 16, 2021 - Study Improving employee voice about transgressive or disruptive behavior: a case study. Citation Text: Dixon-Woods M, Campbell A, Martin G, et al. Improving Employee Voice About Transgressive or Disruptive Behavior: A Case Study. Acad Med. 2019;94(4):579-585. doi:10.1097/ACM.00000000000…

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