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Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. | PSNet

psnet.ahrq.gov/issue/reducing-rate-catheter-associated-bloodstream-infections-surgical-intensive-care-unit-using

November 16, 2022 - Study Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. Citation Text: Sacks GD, Diggs BS, Hadjizacharia P, et al. Reducing the rate of catheter-associated bloodstream infe…

Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit. | PSNet

psnet.ahrq.gov/issue/impact-drug-shortage-medication-errors-and-clinical-outcomes-pediatric-intensive-care-unit

November 16, 2022 - Study Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit. Citation Text: Hughes KM, Goswami ES, Morris JL. Impact of a Drug Shortage on Medication Errors and Clinical Outcomes in the Pediatric Intensive Care Unit. J Pediatr Pharmacol…

Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. | PSNet

psnet.ahrq.gov/issue/causes-medication-administration-errors-hospitals-systematic-review-quantitative-and

April 01, 2015 - Review Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Citation Text: Keers RN, Williams SD, Cooke J, et al. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitativ…

Liability claims and costs before and after implementation of a medical error disclosure program. | PSNet

psnet.ahrq.gov/issue/liability-claims-and-costs-and-after-implementation-medical-error-disclosure-program

April 24, 2018 - Study Classic Liability claims and costs before and after implementation of a medical error disclosure program. Citation Text: Kachalia A, Kaufman SR, Boothman RC, et al. Liability claims and costs before and after implementation of a medical error disclosure …

AHRQ Nursing Home Survey on Patient Safety Culture: 2016 User Comparative Database Report. | PSNet

psnet.ahrq.gov/issue/ahrq-nursing-home-survey-patient-safety-culture-2016-user-comparative-database-report

June 08, 2016 - Government Resource AHRQ Nursing Home Survey on Patient Safety Culture: 2016 User Comparative Database Report. Citation Text: AHRQ Nursing Home Survey on Patient Safety Culture: 2016 User Comparative Database Report. Famolaro T, Yount ND, Greene, K, Hare R, Thorton S, Sorra J. Rockville,…

Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. | PSNet

psnet.ahrq.gov/issue/putting-action-rca2-analysis-intervention-strength-after-adverse-events

April 17, 2024 - Study Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. Citation Text: Zerillo JA, Tardiff SA, Flood D, et al. Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. Jt Comm J Qual Patient Saf. 2024;50(7):492-49…

Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017. | PSNet

psnet.ahrq.gov/issue/prevalence-potentially-inappropriate-medication-prescribing-us-nursing-homes-2013-2017

March 27, 2024 - Study Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017. Citation Text: Riester MR, Goyal P, Steinman MA, et al. Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017. J Gen Intern Med. 2023;38(6):1563-15…

Pediatric trainees' speaking up about unprofessional behavior and traditional patient safety threats. | PSNet

psnet.ahrq.gov/issue/pediatric-trainees-speaking-about-unprofessional-behavior-and-traditional-patient-safety

December 21, 2017 - Study Pediatric trainees' speaking up about unprofessional behavior and traditional patient safety threats. Citation Text: Kesselheim JC, Shelburne JT, Bell SK, et al. Pediatric trainees' speaking up about unprofessional behavior and traditional patient safety threats. Acad Pediatr. 2021…

TeamGAINS: a tool for structured debriefings for simulation-based team trainings. | PSNet

psnet.ahrq.gov/issue/teamgains-tool-structured-debriefings-simulation-based-team-trainings

October 08, 2016 - Study TeamGAINS: a tool for structured debriefings for simulation-based team trainings. Citation Text: Kolbe M, Weiss M, Grote G, et al. TeamGAINS: a tool for structured debriefings for simulation-based team trainings. BMJ Qual Saf. 2013;22(7):541-53. doi:10.1136/bmjqs-2012-000917. Co…

Root cause analysis of adverse events in an outpatient anticoagulation management consortium. | PSNet

psnet.ahrq.gov/issue/root-cause-analysis-adverse-events-outpatient-anticoagulation-management-consortium

March 28, 2012 - Study Root cause analysis of adverse events in an outpatient anticoagulation management consortium. Citation Text: Graves CM, Haymart B, Kline-Rogers E, et al. Root Cause Analysis of Adverse Events in an Outpatient Anticoagulation Management Consortium. Jt Comm J Qual Patient Saf. 2017;4…

The potential for improved teamwork to reduce medical errors in the emergency department. | PSNet

psnet.ahrq.gov/issue/potential-improved-teamwork-reduce-medical-errors-emergency-department

July 07, 2021 - Review Classic The potential for improved teamwork to reduce medical errors in the emergency department. Citation Text: Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in the emergency department. Ann Emerg M…

Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas. | PSNet

psnet.ahrq.gov/issue/deficiencies-facility-leaders-response-critical-surgical-events-michael-e-debakey-va-medical

November 29, 2023 - Book/Report Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas. Citation Text: Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, …

Facilitators and barriers to the implementation of surgical safety checklist (SSC): an integrative review. | PSNet

psnet.ahrq.gov/issue/facilitators-and-barriers-implementation-surgical-safety-checklist-ssc-integrative-review

September 07, 2016 - Review Facilitators and barriers to the implementation of surgical safety checklist (SSC): an integrative review. Citation Text: Lim PJH, Chen L, Siow S, et al. Facilitators and barriers to the implementation of surgical safety checklist: an integrative review. Int J Qual Health Care. 20…

Use of technology to improve the adherence to surgical safety checklists in the operating room. | PSNet

psnet.ahrq.gov/issue/use-technology-improve-adherence-surgical-safety-checklists-operating-room

December 03, 2014 - Study Use of technology to improve the adherence to surgical safety checklists in the operating room. Citation Text: Pati AB, Mishra TS, Chappity P, et al. Use of technology to improve the adherence to surgical safety checklists in the operating room. Jt Comm J Qual Patient Saf. 2023;49(…

Organizational conditions for engagement in quality and safety improvement: a longitudinal qualitative study of community pharmacies. | PSNet

psnet.ahrq.gov/issue/organizational-conditions-engagement-quality-and-safety-improvement-longitudinal-qualitative

November 25, 2020 - Study Organizational conditions for engagement in quality and safety improvement: a longitudinal qualitative study of community pharmacies. Citation Text: Phipps D, Jones CEL, Parker D, et al. Organizational conditions for engagement in quality and safety improvement: a longitudinal qual…

To expand the evidence base about harms from tests and treatments. | PSNet

psnet.ahrq.gov/issue/expand-evidence-base-about-harms-tests-and-treatments

May 19, 2021 - Commentary To expand the evidence base about harms from tests and treatments. Citation Text: Korenstein D, Harris RP, Elshaug AG, et al. To expand the evidence base about harms from tests and treatments. J Gen Intern Med. 2021;36(7):2105-2110. doi:10.1007/s11606-021-06597-9. Copy Citat…

Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center. | PSNet

psnet.ahrq.gov/issue/one-pen-one-patient-achievable-hospital-quality-improvement-project-reduce-risks-inadvertent

April 10, 2024 - Study Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center. Citation Text: Ho S, Stamm R, Hibbs M, et al. Is One-Pen, One-Patient Achievable in the Hospital? A Quality Impr…

The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting. | PSNet

psnet.ahrq.gov/issue/effects-leadership-self-worth-inclusion-trust-and-psychological-safety-medical-error

March 30, 2022 - Study The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting. Citation Text: Brimhall KC, Tsai C-Y, Eckardt R, et al. The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting. …

System-related interventions to reduce diagnostic errors: a narrative review. | PSNet

psnet.ahrq.gov/issue/system-related-interventions-reduce-diagnostic-errors-narrative-review

May 29, 2015 - Review Classic System-related interventions to reduce diagnostic errors: a narrative review. Citation Text: Singh H, Graber ML, Kissam SM, et al. System-related interventions to reduce diagnostic errors: a narrative review. BMJ Qual Saf. 2012;21(2):160-170. do…

Cognitive interventions to reduce diagnostic error: a narrative review. | PSNet

psnet.ahrq.gov/issue/cognitive-interventions-reduce-diagnostic-error-narrative-review

October 16, 2012 - Review Classic Cognitive interventions to reduce diagnostic error: a narrative review. Citation Text: Graber ML, Kissam S, Payne VL, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 2012;21(7):535-557. doi:10.1136/bmjq…

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