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441. Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study. | PSNet
     psnet.ahrq.gov/issue/identifying-and-categorising-patient-safety-hazards-cardiovascular-operating-rooms-using
     August 25, 2015 - Study Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study. Citation Text: Gurses AP, Kim G, Martinez EA, et al. Identifying and categorising patient safety hazards in cardiovascular operating rooms u…

442. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38126/psn-pdf
     December 23, 2012 - The MacArthur Fellows Program: Peter Pronovost. December 23, 2012 The John D. and Catherine T. MacArthur Foundation. https://psnet.ahrq.gov/issue/macarthur-fellows-program-peter-pronovost Through his work, Peter Pronovost, a critical care physician and professor at Johns Hopkins University School of Medicine, has …

443. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854264/psn-pdf
     October 04, 2023 - Patient death tied to lack of proper escalation process for barcode scanning failures. October 4, 2023 ISMP Medication Safety Alert! Acute Care edition. 2023;28(19):1-3. https://psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures Lack of experience with distinct process…

444. Implementation of the Centers for Medicare & Medicaid Services' nonpayment policy for preventable hospital-acquired conditions in rural and nonrural US hospitals. | PSNet
     psnet.ahrq.gov/issue/implementation-centers-medicare-medicaid-services-nonpayment-policy-preventable-hospital
     September 16, 2020 - Study Implementation of the Centers for Medicare & Medicaid Services' nonpayment policy for preventable hospital-acquired conditions in rural and nonrural US hospitals. Citation Text: Bae S-H, Yoder LH. Implementation of the Centers for Medicare & Medicaid Services' Nonpayment Policy for…

445. The impact of COVID-19 response on central line associated bloodstream infections and blood culture contamination rates at a tertiary care center in greater Detroit area. | PSNet
     psnet.ahrq.gov/issue/impact-covid-19-response-central-line-associated-bloodstream-infections-and-blood-culture
     February 07, 2022 - Study The impact of COVID-19 response on central line associated bloodstream infections and blood culture contamination rates at a tertiary care center in greater Detroit area. Citation Text: LeRose J, Sandhu A, Polistico J, et al. The impact of COVID-19 response on central line associat…

446. A systematic review of teamwork in the intensive care unit: what do we know about teamwork, team tasks, and improvement strategies? | PSNet
     psnet.ahrq.gov/issue/systematic-review-teamwork-intensive-care-unit-what-do-we-know-about-teamwork-team-tasks-and
     January 23, 2019 - Review A systematic review of teamwork in the intensive care unit: what do we know about teamwork, team tasks, and improvement strategies? Citation Text: Dietz AS, Pronovost P, Mendez-Tellez PA, et al. A systematic review of teamwork in the intensive care unit: what do we know about team…

447. Healthcare-associated infections in Veterans Affairs acute-care and long-term healthcare facilities during the coronavirus disease 2019 (COVID-19) pandemic. | PSNet
     psnet.ahrq.gov/issue/healthcare-associated-infections-veterans-affairs-acute-care-and-long-term-healthcare
     February 07, 2022 - Study Healthcare-associated infections in Veterans Affairs acute-care and long-term healthcare facilities during the coronavirus disease 2019 (COVID-19) pandemic. Citation Text: Evans ME, Simbartl LA, Kralovic SM, et al. Healthcare-associated infections in Veterans Affairs acute-care and…

448. Medication errors in the outpatient setting: classification and root cause analysis. | PSNet
     psnet.ahrq.gov/issue/medication-errors-outpatient-setting-classification-and-root-cause-analysis
     December 16, 2020 - Study Medication errors in the outpatient setting: classification and root cause analysis. Citation Text: Friedman AL, Geoghegan SR, Sowers NM, et al. Medication errors in the outpatient setting: classification and root cause analysis. Arch Surg. 2007;142(3):278-83; discussion 284. Cop…

449. Home health staff perspectives on infection prevention and control: implications for Coronavirus Disease 2019. | PSNet
     psnet.ahrq.gov/issue/home-health-staff-perspectives-infection-prevention-and-control-implications-coronavirus
     October 28, 2020 - Study Home health staff perspectives on infection prevention and control: implications for Coronavirus Disease 2019. Citation Text: Pogorzelska-Maziarz M, Chastain AM, Mangal S, et al. Home health staff perspectives on infection prevention and control: implications for Coronavirus Diseas…

450. Vital signs: improving antibiotic use among hospitalized patients. | PSNet
     psnet.ahrq.gov/issue/vital-signs-improving-antibiotic-use-among-hospitalized-patients
     February 27, 2019 - Study Classic Vital signs: improving antibiotic use among hospitalized patients. Citation Text: Fridkin SK, Baggs J, Fagan R, et al. Vital signs: improving antibiotic use among hospitalized patients. MMWR Morb Mortal Wkly Rep. 2014;63(9):194-200. Copy Citation…

451. COVID-19 increased the risk of ICU-acquired bloodstream infections: a case-cohort study from the multicentric OUTCOMEREA network. | PSNet
     psnet.ahrq.gov/issue/covid-19-increased-risk-icu-acquired-bloodstream-infections-case-cohort-study-multicentric
     March 11, 2020 - Study COVID-19 increased the risk of ICU-acquired bloodstream infections: a case-cohort study from the multicentric OUTCOMEREA network. Citation Text: Buetti N, Ruckly S, de Montmollin E, et al. COVID-19 increased the risk of ICU-acquired bloodstream infections: a case–cohort study from …

452. Association of a Safety Program for Improving Antibiotic Use with antibiotic use and hospital-onset Clostridioides difficile infection rates among US hospitals | PSNet
     psnet.ahrq.gov/issue/association-safety-program-improving-antibiotic-use-antibiotic-use-and-hospital-onset
     July 20, 2022 - Study Association of a Safety Program for Improving Antibiotic Use with antibiotic use and hospital-onset Clostridioides difficile infection rates among US hospitals Citation Text: Tamma PD, Miller MA, Dullabh P, et al. Association of a safety program for improving antibiotic use with an…

453. Latex: a lingering and lurking safety risk. | PSNet
     psnet.ahrq.gov/issue/latex-lingering-and-lurking-safety-risk
     October 03, 2018 - Newspaper/Magazine Article Latex: a lingering and lurking safety risk. Citation Text: Latex: a lingering and lurking safety risk. Liberatore K. PA-PSRS Patient Saf Advis. 2018 March;15. Copy Citation Save Save to your library Print Download PDF S…

454. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41879/psn-pdf
     January 18, 2013 - Retrieval of iatrogenic intravascular foreign bodies. January 18, 2013 Schechter MA, O'Brien PJ, Cox MW. Retrieval of iatrogenic intravascular foreign bodies. J Vasc Surg. 2013;57(1):276-81. doi:10.1016/j.jvs.2012.09.002. https://psnet.ahrq.gov/issue/retrieval-iatrogenic-intravascular-foreign-bodies This review ar…

455. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837334/psn-pdf
     June 08, 2022 - Safety gaps in medical team communication: closing the loop on quality improvement efforts in the cardiac catheterization lab. June 8, 2022 Doorey AJ, Turi ZG, Lazzara EH, et al. Safety gaps in medical team communication: closing the loop on quality improvement efforts in the cardiac catheterization lab. Catheter …

456. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33864/psn-pdf
     January 01, 2019 - How Does Health Care Simulation Affect Patient Care? August 1, 2018 Lopreiato JO. How Does Health Care Simulation Affect Patient Care? PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care Perspective Introduction Health care simulation programs have spread…

457. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47412/psn-pdf
     October 31, 2018 - The systems approach at the sharp end. October 31, 2018 Cross SRH. The systems approach at the sharp end. Future Healthc J. 2019;5(3):176-180. doi:10.7861/futurehosp.5-3-176. https://psnet.ahrq.gov/issue/systems-approach-sharp-end Systems solutions are often focused on creating improvements at the organizational o…

458. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44274/psn-pdf
     February 18, 2019 - Concepts for the development of a customizable checklist for use by patients. February 18, 2019 Fernando RJ, Shapiro FE, Rosenberg NM, et al. Concepts for the Development of a Customizable Checklist for Use by Patients. J Patient Saf. 2019;15(1):18-23. doi:10.1097/PTS.0000000000000203. https://psnet.ahrq.gov/issue…

459. A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes. | PSNet
     psnet.ahrq.gov/issue/systematic-review-unintended-consequences-clinical-interventions-reduce-adverse-outcomes
     November 15, 2023 - Review A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes. Citation Text: Manojlovich M, Lee S, Lauseng D. A Systematic Review of the Unintended Consequences of Clinical Interventions to Reduce Adverse Outcomes. J Patient Saf. 2016;12(…

460. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45540/psn-pdf
     November 01, 2016 - Performing the wrong procedure. November 1, 2016 Minnier T, Phrampus P, Waddell L. Performing the Wrong Procedure. JAMA. 2016;316(11):1207-1208. doi:10.1001/jama.2016.9134. https://psnet.ahrq.gov/issue/performing-wrong-procedure Describing an incorrect procedure incident which involved placement of a dialysis cath…