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  1. Using root cause analysis to reduce falls with injury in community settings. | PSNet

    psnet.ahrq.gov/issue/using-root-cause-analysis-reduce-falls-injury-community-settings
    April 25, 2016 - Study Using root cause analysis to reduce falls with injury in community settings. Citation Text: Lee A, Mills PD, Neily J. Using root cause analysis to reduce falls with injury in community settings. Jt Comm J Qual Patient Saf. 2012;38(8):366-374. Copy Citation Format: Goo…

  2. The consequences of misdiagnosing race-based trauma response in Black men: a critical examination. | PSNet

    psnet.ahrq.gov/issue/consequences-misdiagnosing-race-based-trauma-response-black-men-critical-examination
    November 16, 2022 - Commentary The consequences of misdiagnosing race-based trauma response in Black men: a critical examination. Citation Text: Sanders AA, Roberts JD, McDowell MC, et al. The consequences of misdiagnosing race-based trauma response in Black men: a critical examination. Soc Work Public Heal…

  3. Preventable morbidity at a mature trauma center. | PSNet

    psnet.ahrq.gov/issue/preventable-morbidity-mature-trauma-center
    September 22, 2021 - Study Preventable morbidity at a mature trauma center. Citation Text: Preventable morbidity at a mature trauma center. Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144(6):536-541. Copy Citation Save Save to your library Print Download PDF …

  4. Postoperative handover: problems, pitfalls, and prevention of error. | PSNet

    psnet.ahrq.gov/issue/postoperative-handover-problems-pitfalls-and-prevention-error
    September 26, 2012 - Image/Poster Postoperative handover: problems, pitfalls, and prevention of error. Citation Text: Nagpal K, Arora S, Abboudi M, et al. Postoperative handover: problems, pitfalls, and prevention of error. Ann Surg. 2010;252(1):171-6. doi:10.1097/SLA.0b013e3181dc3656. Copy Citation …

  5. Representative case series from public hospital admissions 1998 II: surgical adverse events. | PSNet

    psnet.ahrq.gov/issue/representative-case-series-public-hospital-admissions-1998-ii-surgical-adverse-events
    June 07, 2023 - Study Representative case series from public hospital admissions 1998 II: surgical adverse events. Citation Text: Briant R, Morton J, Lay-Yee R, et al. Representative case series from public hospital admissions 1998 II: surgical adverse events. N Z Med J. 2005;118(1219):U1591. Copy C…

  6. Care at the point of impact: insights into the second-victim experience. | PSNet

    psnet.ahrq.gov/issue/care-point-impact-insights-second-victim-experience
    January 03, 2017 - Commentary Care at the point of impact: insights into the second-victim experience. Citation Text: Scott SD, McCoig MM. Care at the point of impact: Insights into the second-victim experience. J Healthc Risk Manag. 2016;35(4):6-13. doi:10.1002/jhrm.21218. Copy Citation Format: …

  7. Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system. | PSNet

    psnet.ahrq.gov/issue/prevention-wrong-location-misadministration-through-use-intradepartmental-incident-learning
    January 22, 2017 - Study Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system. Citation Text: Ford E, Smith K, Harris K, et al. Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system. M…

  8. Prioritising recommendations following analyses of adverse events in healthcare: a systematic review. | PSNet

    psnet.ahrq.gov/issue/prioritising-recommendations-following-analyses-adverse-events-healthcare-systematic-review
    April 20, 2022 - Review Prioritising recommendations following analyses of adverse events in healthcare: a systematic review. Citation Text: Bos K, van der Laan MJ, Dongelmans DA. Prioritising recommendations following analyses of adverse events in healthcare: a systematic review. BMJ Open Qual. 2020;9(4…

  9. Considerations for the design of safe and effective consumer health IT applications in the home. | PSNet

    psnet.ahrq.gov/issue/considerations-design-safe-and-effective-consumer-health-it-applications-home
    September 24, 2016 - Study Considerations for the design of safe and effective consumer health IT applications in the home. Citation Text: Zayas-Cabán T, Dixon BE. Considerations for the design of safe and effective consumer health IT applications in the home. Qual Saf Health Care. 2010;19 Suppl 3:i61-i67.…

  10. Time-out and checklists: a survey of rural and urban operating room personnel. | PSNet

    psnet.ahrq.gov/issue/time-out-and-checklists-survey-rural-and-urban-operating-room-personnel
    January 09, 2014 - Study Time-out and checklists: a survey of rural and urban operating room personnel. Citation Text: Lyons VE, Popejoy LL. Time-Out and Checklists: A Survey of Rural and Urban Operating Room Personnel. J Nurs Care Qual. 2017;32(1):E3-E10. Copy Citation Format: Google Scholar…

  11. Surgical safety checklist compliance: a job done poorly! | PSNet

    psnet.ahrq.gov/issue/surgical-safety-checklist-compliance-job-done-poorly
    April 25, 2016 - Study Surgical safety checklist compliance: a job done poorly! Citation Text: Sparks EA, Wehbe-Janek H, Johnson RL, et al. Surgical Safety Checklist compliance: a job done poorly!. J Am Coll Surg. 2013;217(5):867-73.e1-3. doi:10.1016/j.jamcollsurg.2013.07.393. Copy Citation Forma…

  12. An overview of the use and implementation of checklists in surgical specialities - a systematic review. | PSNet

    psnet.ahrq.gov/issue/overview-use-and-implementation-checklists-surgical-specialities-systematic-review
    July 31, 2013 - Review An overview of the use and implementation of checklists in surgical specialities - a systematic review. Citation Text: Patel J, Ahmed K, Guru KA, et al. An overview of the use and implementation of checklists in surgical specialities - a systematic review. Int J Surg. 2014;12(12):…

  13. How to monitor patient safety in primary care? Healthcare professionals' views. | PSNet

    psnet.ahrq.gov/issue/how-monitor-patient-safety-primary-care-healthcare-professionals-views
    December 14, 2016 - Study How to monitor patient safety in primary care? Healthcare professionals' views. Citation Text: Samra R, Car J, Majeed A, et al. How to monitor patient safety in primary care? Healthcare professionals' views. JRSM Open. 2016;7(8):2054270416648045. doi:10.1177/2054270416648045. Cop…

  14. STAMP: a 5-year project to reduce paediatric prescribing errors. | PSNet

    psnet.ahrq.gov/issue/stamp-5-year-project-reduce-paediatric-prescribing-errors
    June 26, 2019 - Study STAMP: a 5-year project to reduce paediatric prescribing errors. Citation Text: Trivedi A, Ajitsaria R, Bate T. STAMP: a 5-year project to reduce paediatric prescribing errors. Arch Dis Child Educ Pract Ed. 2022;108(2):115-119. doi:10.1136/archdischild-2021-323192. Copy Citation …

  15. Taking patients' narratives about clinicians from anecdote to science. | PSNet

    psnet.ahrq.gov/issue/taking-patients-narratives-about-clinicians-anecdote-science
    March 20, 2019 - Commentary Taking patients' narratives about clinicians from anecdote to science. Citation Text: Schlesinger M, Grob R, Shaller D, et al. Taking Patients' Narratives about Clinicians from Anecdote to Science. New Engl J Med. 2015;373(7):675-679. doi:10.1056/NEJMsb1502361. Copy Citation…

  16. Lack of timely follow-up of abnormal imaging results and radiologists' recommendations. | PSNet

    psnet.ahrq.gov/issue/lack-timely-follow-abnormal-imaging-results-and-radiologists-recommendations
    April 13, 2017 - Study Lack of timely follow-up of abnormal imaging results and radiologists' recommendations. Citation Text: Al-Mutairi A, Meyer AND, Chang P, et al. Lack of timely follow-up of abnormal imaging results and radiologists' recommendations. J Am Coll Radiol. 2015;12(4):385-389. doi:10.1016/…

  17. Practice indicators of suboptimal care and avoidable adverse events: a content analysis of a national qualifying examination. | PSNet

    psnet.ahrq.gov/issue/practice-indicators-suboptimal-care-and-avoidable-adverse-events-content-analysis-national
    May 13, 2015 - Study Practice indicators of suboptimal care and avoidable adverse events: a content analysis of a national qualifying examination. Citation Text: Bordage G, Meguerditchian A-N, Tamblyn R. Practice indicators of suboptimal care and avoidable adverse events: a content analysis of a natio…

  18. Addressing the elephant in the room: a shame resilience seminar for medical students. | PSNet

    psnet.ahrq.gov/issue/addressing-elephant-room-shame-resilience-seminar-medical-students
    June 07, 2023 - Commentary Addressing the elephant in the room: a shame resilience seminar for medical students. Citation Text: Bynum WE, Adams A, Edelman CE, et al. Addressing the Elephant in the Room: A Shame Resilience Seminar for Medical Students. Acad Med. 2019;94(8):1132-1136. doi:10.1097/ACM.0000…

  19. Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. | PSNet

    psnet.ahrq.gov/issue/prospective-memory-icu-effect-visual-cues-task-execution-representative-simulation
    April 24, 2018 - Study Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. Citation Text: Grundgeiger T, Sanderson PM, Orihuela B, et al. Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. Ergo…

  20. The nature and occurrence of registration errors in the emergency department. | PSNet

    psnet.ahrq.gov/issue/nature-and-occurrence-registration-errors-emergency-department
    September 28, 2016 - Study The nature and occurrence of registration errors in the emergency department. Citation Text: Hakimzada AF, Green RA, Sayan OR, et al. The nature and occurrence of registration errors in the emergency department. Int J Med Inform. 2007;77(3). doi:10.1016/j.ijmedinf.2007.04.011. …
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