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  1. A theoretical framework and competency-based approach to improving handoffs. | PSNet

    psnet.ahrq.gov/issue/theoretical-framework-and-competency-based-approach-improving-handoffs
    March 28, 2011 - Commentary A theoretical framework and competency-based approach to improving handoffs. Citation Text: Arora VM, Johnson JK, Meltzer DO, et al. A theoretical framework and competency-based approach to improving handoffs. Qual Saf Health Care. 2008;17(1):11-4. doi:10.1136/qshc.2006.0189…

  2. Surgical intraoperative handoff initiative: standardizing operating room communication using SHRIMPS. | PSNet

    psnet.ahrq.gov/issue/surgical-intraoperative-handoff-initiative-standardizing-operating-room-communication-using
    October 04, 2023 - Study Surgical intraoperative handoff initiative: standardizing operating room communication using SHRIMPS. Citation Text: Stephens WA, Anderson MJ, Levy BE, et al. Surgical intraoperative handoff initiative: standardizing operating room communication using SHRIMPS. J Am Coll Surg. 2024;…

  3. Seen through the patients' eyes: safety of chronic illness care. | PSNet

    psnet.ahrq.gov/issue/seen-through-patients-eyes-safety-chronic-illness-care
    May 16, 2018 - Study Seen through the patients' eyes: safety of chronic illness care. Citation Text: Desmedt M, Petrovic M, Bergs J, et al. Seen through the patients' eyes: Safety of chronic illness care. Int J Qual Health Care. 2017;29(7):916-921. doi:10.1093/intqhc/mzx137. Copy Citation Format:…

  4. Doctors' stress responses and poor communication performance in simulated bad-news consultations. | PSNet

    psnet.ahrq.gov/issue/doctors-stress-responses-and-poor-communication-performance-simulated-bad-news-consultations
    July 19, 2023 - Study Doctors' stress responses and poor communication performance in simulated bad-news consultations. Citation Text: Brown R, Dunn S, Byrnes K, et al. Doctors' stress responses and poor communication performance in simulated bad-news consultations. Acad Med. 2009;84(11):1595-602. doi…

  5. A call for safety: anticipating and mitigating risk across an obstetrics and gynecology service line. | PSNet

    psnet.ahrq.gov/issue/call-safety-anticipating-and-mitigating-risk-across-obstetrics-and-gynecology-service-line
    February 24, 2016 - Commentary A call for safety: anticipating and mitigating risk across an obstetrics and gynecology service line. Citation Text: Combs A, Klein VR. A call for safety: anticipating and mitigating risk across an obstetrics and gynecology service line. J Healthc Risk Manag. 2023;43(1):38-42.…

  6. Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk. | PSNet

    psnet.ahrq.gov/issue/improving-handoff-communications-critical-care-utilizing-simulation-based-training-toward
    February 16, 2011 - Study Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk. Citation Text: Berkenstadt H, Haviv Y, Tuval A, et al. Improving handoff communications in critical care: utilizing simulation-based training …

  7. Psychological safety, communication openness, nurse job outcomes, and patient safety in hospital nurses. | PSNet

    psnet.ahrq.gov/issue/psychological-safety-communication-openness-nurse-job-outcomes-and-patient-safety-hospital
    August 19, 2020 - Study Psychological safety, communication openness, nurse job outcomes, and patient safety in hospital nurses. Citation Text: Cho H, Steege LM, Arsenault Knudsen ÉN. Psychological safety, communication openness, nurse job outcomes, and patient safety in hospital nurses. Res Nurs Health. …

  8. Is communication improved with the implementation of an obstetrical version of the World Health Organization safe surgery checklist? | PSNet

    psnet.ahrq.gov/issue/communication-improved-implementation-obstetrical-version-world-health-organization-safe
    February 02, 2022 - Study Is communication improved with the implementation of an obstetrical version of the World Health Organization safe surgery checklist? Citation Text: Govindappagari S, Guardado A, Goffman D, et al. Is Communication Improved With the Implementation of an Obstetrical Version of the Wor…

  9. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. | PSNet

    psnet.ahrq.gov/issue/analysis-surgical-errors-closed-malpractice-claims-4-liability-insurers
    February 17, 2011 - Study Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Citation Text: Rogers SO, Gawande AA, Kwaan M, et al. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery. 2006;140(1):25-33. Copy Citation Format: …

  10. Incorrect surgical counts: a qualitative analysis. | PSNet

    psnet.ahrq.gov/issue/incorrect-surgical-counts-qualitative-analysis
    September 12, 2012 - Study Incorrect surgical counts: a qualitative analysis. Citation Text: Rowlands A, Steeves R. Incorrect surgical counts: a qualitative analysis. AORN J. 2010;92(4):410-9. doi:10.1016/j.aorn.2010.01.019. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33569/psn-pdf
    June 15, 2024 - Readmissions and Adverse Events After Discharge June 15, 2024 Readmissions and Adverse Events After Discharge. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that t…

  12. Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
    January 01, 2023 - • In addition, debriefing after simulation sessions can reinforce the importance of knowing and communicating

  13. Patient Safety During Hospital Discharge | PSNet

    psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
    April 01, 2018 - We never saw them as a tool for communication or as essential to communicating what happened in the hospital

  14. Eptifibatide Epilogue | PSNet

    psnet.ahrq.gov/web-mm/eptifibatide-epilogue
    March 04, 2011 - Eptifibatide Epilogue Citation Text: Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …

  15. How to Identify and Manage Problem Behaviors | PSNet

    psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
    December 01, 2009 - How to Identify and Manage Problem Behaviors Alan H. Rosenstein, MD, MBA; Michelle O'Daniel, MSG, MHA | December 1, 2009  Also Read a Conversation View more articles from the same authors. Citation Text: Rosenstein AH, O'Daniel M. How to Identify and Manage Prob…

  16. Incidence, patterns, and prevention of wrong-site surgery. | PSNet

    psnet.ahrq.gov/issue/incidence-patterns-and-prevention-wrong-site-surgery
    September 30, 2010 - Study Classic Incidence, patterns, and prevention of wrong-site surgery. Citation Text: Kwaan MR, Studdert DM, Zinner MJ, et al. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg. 2006;141(4):353-358. Copy Citation Format: Goog…

  17. Using an inpatient portal to engage families in pediatric hospital care. | PSNet

    psnet.ahrq.gov/issue/using-inpatient-portal-engage-families-pediatric-hospital-care
    September 13, 2023 - Study Using an inpatient portal to engage families in pediatric hospital care. Citation Text: Kelly MM, Hoonakker P, Dean SM. Using an inpatient portal to engage families in pediatric hospital care. J Am Med Inform Assoc. 2017;24(1):153-161. doi:10.1093/jamia/ocw070. Copy Citation …

  18. Adverse events in patients transitioning from the emergency department to the inpatient setting. | PSNet

    psnet.ahrq.gov/issue/adverse-events-patients-transitioning-emergency-department-inpatient-setting
    September 07, 2022 - Study Adverse events in patients transitioning from the emergency department to the inpatient setting. Citation Text: Tsilimingras D, Schnipper JL, Zhang L, et al. Adverse events in patients transitioning from the emergency department to the inpatient setting. J Patient Saf. 2024;20(8):5…

  19. Tackling communication barriers between long-term care facility and emergency department transfers to improve medication safety in older adults. | PSNet

    psnet.ahrq.gov/issue/tackling-communication-barriers-between-long-term-care-facility-and-emergency-department
    August 02, 2017 - Commentary Tackling communication barriers between long-term care facility and emergency department transfers to improve medication safety in older adults. Citation Text: Callinan SM, Brandt NJ. Tackling communication barriers between long-term care facility and emergency department tran…

  20. Challenging authority and speaking up in the operating room environment: a narrative synthesis. | PSNet

    psnet.ahrq.gov/issue/challenging-authority-and-speaking-operating-room-environment-narrative-synthesis
    December 13, 2017 - Review Emerging Classic Challenging authority and speaking up in the operating room environment: a narrative synthesis. Citation Text: Pattni N, Arzola C, Malavade A, et al. Challenging authority and speaking up in the operating room environment: a narrative syn…
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