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  1. Error codes at autopsy to study potential biases in diagnostic error. | PSNet

    psnet.ahrq.gov/issue/error-codes-autopsy-study-potential-biases-diagnostic-error
    November 30, 2012 - Study Error codes at autopsy to study potential biases in diagnostic error. Citation Text: Goldman BI, Bharadwaj R, Fuller M, et al. Error codes at autopsy to study potential biases in diagnostic error. Diagnosis (Berl). 2023;10(4):375-382. doi:10.1515/dx-2023-0010. Copy Citation F…

  2. Proactive patient safety: focusing on what goes right in the perioperative environment. | PSNet

    psnet.ahrq.gov/issue/proactive-patient-safety-focusing-what-goes-right-perioperative-environment
    April 26, 2023 - Study Proactive patient safety: focusing on what goes right in the perioperative environment. Citation Text: Duffy C, Menon N, Horak D, et al. Proactive patient safety: focusing on what goes right in the perioperative environment. J Patient Saf. 2023;19(4):281-286. doi:10.1097/pts.000000…

  3. Nursing crew resource management: a follow-up report from the Veterans Health Administration. | PSNet

    psnet.ahrq.gov/issue/nursing-crew-resource-management-follow-report-veterans-health-administration
    September 27, 2016 - Commentary Nursing crew resource management: a follow-up report from the Veterans Health Administration. Citation Text: Sculli GL, Fore AM, West P, et al. Nursing crew resource management: a follow-up report from the Veterans Health Administration. J Nurs Adm. 2013;43(3):122-6. doi:10.1…

  4. Electronic detection of delayed test result follow-up in patients with hypothyroidism. | PSNet

    psnet.ahrq.gov/issue/electronic-detection-delayed-test-result-follow-patients-hypothyroidism
    September 27, 2017 - Study Electronic detection of delayed test result follow-up in patients with hypothyroidism. Citation Text: Meyer AND, Murphy DR, Al-Mutairi A, et al. Electronic Detection of Delayed Test Result Follow-Up in Patients with Hypothyroidism. J Gen Intern Med. 2017;32(7). doi:10.1007/s11606-0…

  5. Team situation awareness and the anticipation of patient progress during ICU rounds. | PSNet

    psnet.ahrq.gov/issue/team-situation-awareness-and-anticipation-patient-progress-during-icu-rounds
    May 06, 2009 - Study Team situation awareness and the anticipation of patient progress during ICU rounds. Citation Text: Reader TW, Flin R, Mearns K, et al. Team situation awareness and the anticipation of patient progress during ICU rounds. BMJ Qual Saf. 2011;20(12):1035-42. doi:10.1136/bmjqs.2010.0…

  6. Sailing too close to the wind? How harnessing patient voice can identify drift towards boundaries of acceptable performance. | PSNet

    psnet.ahrq.gov/issue/sailing-too-close-wind-how-harnessing-patient-voice-can-identify-drift-towards-boundaries
    February 28, 2024 - Commentary Sailing too close to the wind? How harnessing patient voice can identify drift towards boundaries of acceptable performance. Citation Text: Wiig S, Calderwood CJ, O’Hara J. Sailing too close to the wind? How harnessing patient voice can identify drift towards boundaries of acc…

  7. A systematic integrative review of specialized nurses' role to establish a culture of patient safety: a modelling perspective. | PSNet

    psnet.ahrq.gov/issue/systematic-integrative-review-specialized-nurses-role-establish-culture-patient-safety
    July 10, 2024 - Review A systematic integrative review of specialized nurses' role to establish a culture of patient safety: a modelling perspective. Citation Text: Glarcher M, Vaismoradi M. A systematic integrative review of specialized nurses' role to establish a culture of patient safety: a modelling…

  8. Analysis of medication prescribing errors in critically ill children. | PSNet

    psnet.ahrq.gov/issue/analysis-medication-prescribing-errors-critically-ill-children
    March 28, 2012 - Study Analysis of medication prescribing errors in critically ill children. Citation Text: Glanzmann C, Frey B, Meier CR, et al. Analysis of medication prescribing errors in critically ill children. Eur J Pediatr. 2015;174(10):1347-1355. doi:10.1007/s00431-015-2542-4. Copy Citation …

  9. Development of trigger tools for surveillance of adverse events in ambulatory surgery. | PSNet

    psnet.ahrq.gov/issue/development-trigger-tools-surveillance-adverse-events-ambulatory-surgery
    October 01, 2014 - Study Development of trigger tools for surveillance of adverse events in ambulatory surgery. Citation Text: Kaafarani HMA, Rosen AK, Nebeker JR, et al. Development of trigger tools for surveillance of adverse events in ambulatory surgery. Qual Saf Health Care. 2010;19(5):425-9. doi:10.…

  10. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. | PSNet

    psnet.ahrq.gov/issue/development-and-pilot-evaluation-preoperative-briefing-protocol-cardiovascular-surgery
    September 27, 2016 - Study Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. Citation Text: Henrickson SE, Wadhera RK, Elbardissi AW, et al. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. J Am Coll Surg. 2009;20…

  11. Patient safety informatics: meeting the challenges of emerging digital health. | PSNet

    psnet.ahrq.gov/issue/patient-safety-informatics-meeting-challenges-emerging-digital-health
    June 08, 2022 - Commentary Patient safety informatics: meeting the challenges of emerging digital health. Citation Text: McInerney C, Benn J, Dowding D, et al. Patient safety informatics: meeting the challenges of emerging digital health. Stud Health Technol Inform. 2022;290:364-368. doi:10.3233/shti220…

  12. Performance characteristics of a methodology to quantify adverse events over time in hospitalized patients. | PSNet

    psnet.ahrq.gov/issue/performance-characteristics-methodology-quantify-adverse-events-over-time-hospitalized
    December 01, 2010 - Study Performance characteristics of a methodology to quantify adverse events over time in hospitalized patients. Citation Text: Sharek PJ, Parry G, Goldmann DA, et al. Performance characteristics of a methodology to quantify adverse events over time in hospitalized patients. Health Se…

  13. Patient safety and ethical implications of healthcare sick leave policies in the pandemic era. | PSNet

    psnet.ahrq.gov/issue/patient-safety-and-ethical-implications-healthcare-sick-leave-policies-pandemic-era
    September 16, 2020 - Commentary Patient safety and ethical implications of healthcare sick leave policies in the pandemic era. Citation Text: Preston-Suni K, Celedon MA, Cordasco KM. Patient safety and ethical implications of healthcare sick leave policies in the pandemic era. Jt Comm J Qual Patient Saf. 202…

  14. Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices. | PSNet

    psnet.ahrq.gov/issue/novel-use-electronic-whiteboard-operating-room-increases-surgical-team-compliance-pre
    March 20, 2013 - Study Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices. Citation Text: Mainthia R, Lockney T, Zotov A, et al. Novel use of electronic whiteboard in the operating room increases surgical team compliance with p…

  15. Identification of poor performance in a national medical workforce over 11 years: an observational study. | PSNet

    psnet.ahrq.gov/issue/identification-poor-performance-national-medical-workforce-over-11-years-observational-study
    August 12, 2014 - Study Identification of poor performance in a national medical workforce over 11 years: an observational study. Citation Text: Donaldson LJ, Panesar S, McAvoy PA, et al. Identification of poor performance in a national medical workforce over 11 years: an observational study. BMJ Qual Sa…

  16. Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis. | PSNet

    psnet.ahrq.gov/issue/frequency-and-type-situational-awareness-errors-contributing-death-and-brain-damage-closed
    September 01, 2021 - Study Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis. Citation Text: Schulz CM, Burden A, Posner KL, et al. Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage: A Closed Claims Anal…

  17. Executive/senior leader checklist to improve culture and reduce central line–associated bloodstream infections. | PSNet

    psnet.ahrq.gov/issue/executivesenior-leader-checklist-improve-culture-and-reduce-central-line-associated
    August 25, 2010 - Commentary Executive/senior leader checklist to improve culture and reduce central line–associated bloodstream infections. Citation Text: Goeschel CA, Holzmueller CG, Berenholtz SM, et al. Executive/Senior Leader Checklist to improve culture and reduce central line-associated bloodstream…

  18. Developing and pilot testing practical measures of preanalytic surgical specimen identification defects. | PSNet

    psnet.ahrq.gov/issue/developing-and-pilot-testing-practical-measures-preanalytic-surgical-specimen-identification
    June 16, 2011 - Study Developing and pilot testing practical measures of preanalytic surgical specimen identification defects. Citation Text: Bixenstine PJ, Zarbo RJ, Holzmueller CG, et al. Developing and pilot testing practical measures of preanalytic surgical specimen identification defects. Am J M…

  19. Evaluation of a nurse-led safety program in a critical care unit. | PSNet

    psnet.ahrq.gov/issue/evaluation-nurse-led-safety-program-critical-care-unit
    June 03, 2013 - Study Evaluation of a nurse-led safety program in a critical care unit. Citation Text: Saladino L, Pickett LC, Frush K, et al. Evaluation of a nurse-led safety program in a critical care unit. J Nurs Care Qual. 2013;28(2):139-46. doi:10.1097/NCQ.0b013e31827464c3. Copy Citation F…

  20. Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentations to 251 medical students. | PSNet

    psnet.ahrq.gov/issue/using-nam-diagnostic-process-framework-teach-clinical-reasoning-computerized-case
    December 07, 2022 - Study Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentations to 251 medical students. Citation Text: Covin Y, Longo P, Wick N, et al. Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentatio…
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