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  1. A sudden death with lung embolism after inadvertent infusion of zinc oxide shake lotion. | PSNet

    psnet.ahrq.gov/issue/sudden-death-lung-embolism-after-inadvertent-infusion-zinc-oxide-shake-lotion
    January 12, 2022 - Commentary A sudden death with lung embolism after inadvertent infusion of zinc oxide shake lotion. Citation Text: Pragst F, Correns A, Priem F, et al. A sudden death with lung embolism after inadvertent infusion of zinc oxide shake lotion. Forensic Sci Int. 2007;170(2-3):207-12. Cop…

  2. Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research. | PSNet

    psnet.ahrq.gov/issue/quality-outpatient-clinical-notes-stakeholder-definition-derived-through-qualitative-research
    September 09, 2013 - Study Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research. Citation Text: Hanson JL, Stephens MB, Pangaro LN, et al. Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research. BMC Health Serv Res. …

  3. At risk care plans: a way to reduce readmissions and adverse events. | PSNet

    psnet.ahrq.gov/issue/risk-care-plans-way-reduce-readmissions-and-adverse-events
    October 27, 2010 - Commentary At risk care plans: a way to reduce readmissions and adverse events. Citation Text: Bahle J, Majercik C, Ludwick R, et al. At Risk Care Plans: a way to reduce readmissions and adverse events. J Nurs Care Qual. 2015;30(3):200-4. doi:10.1097/NCQ.0000000000000106. Copy Citation…

  4. Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. | PSNet

    psnet.ahrq.gov/issue/effect-comprehensive-obstetric-patient-safety-program-compensation-payments-and-sentinel
    July 26, 2010 - Study Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. Citation Text: Grunebaum A, Chervenak F, Skupski D. Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. Am J Obstet Gyneco…

  5. Delivering high reliability in maternity care: in situ simulation as a source of organisational resilience. | PSNet

    psnet.ahrq.gov/issue/delivering-high-reliability-maternity-care-situ-simulation-source-organisational-resilience
    April 05, 2023 - Commentary Emerging Classic Delivering high reliability in maternity care: in situ simulation as a source of organisational resilience. Citation Text: Macrae C, Draycott T. Delivering high reliability in maternity care: In situ simulation as a source of organisa…

  6. A coaching program to improve employee engagement, culture of safety, and patient experience. | PSNet

    psnet.ahrq.gov/issue/coaching-program-improve-employee-engagement-culture-safety-and-patient-experience
    April 05, 2013 - Study A coaching program to improve employee engagement, culture of safety, and patient experience. Citation Text: Scheurer D, Coulter A, Harper K, et al. A coaching program to improve employee engagement, culture of safety, and patient experience. NEJM Catalyst. 2024;6(1):CAT.24.0225. d…

  7. Restorative just culture: an exploration of the enabling conditions for successful implementation. | PSNet

    psnet.ahrq.gov/issue/restorative-just-culture-exploration-enabling-conditions-successful-implementation
    February 08, 2023 - Study Restorative just culture: an exploration of the enabling conditions for successful implementation. Citation Text: Boskeljon-Horst L, Steinmetz V, Dekker SWA. Restorative just culture: an exploration of the enabling conditions for successful implementation. Healthcare (Basel). 2024;…

  8. Patient Safety and the "Just Culture": A Primer for Health Care Executives. | PSNet

    psnet.ahrq.gov/issue/patient-safety-and-just-culture-primer-health-care-executives
    July 24, 2013 - Book/Report Classic Patient Safety and the "Just Culture": A Primer for Health Care Executives. Citation Text: Marx DA. Patient Safety And The "Just Culture": A Primer For Health Care Executives. New York, NY: Trustees of Columbia University; 2001. Copy Citati…

  9. Fostering transparency in outcomes, quality, safety, and costs. | PSNet

    psnet.ahrq.gov/issue/fostering-transparency-outcomes-quality-safety-and-costs
    January 29, 2015 - Commentary Fostering transparency in outcomes, quality, safety, and costs. Citation Text: Austin M, McGlynn EA, Pronovost P. Fostering Transparency in Outcomes, Quality, Safety, and Costs. JAMA. 2016;316(16):1661-1662. doi:10.1001/jama.2016.14039. Copy Citation Format: DOI …

  10. Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders. | PSNet

    psnet.ahrq.gov/issue/rethinking-patient-safety-discussion-guide-patients-healthcare-providers-and-leaders
    August 24, 2022 - Toolkit Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders. Citation Text: Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders. Gilbert R, Asselbergs M, Davis D, et al. Healthcare Excellence Canada; 2023. …

  11. Preventing unintended retained foreign objects. | PSNet

    psnet.ahrq.gov/issue/preventing-unintended-retained-foreign-objects
    January 25, 2023 - Sentinel Event Alerts Preventing unintended retained foreign objects. Citation Text: Preventing unintended retained foreign objects. Sentinel event alert. 2013;(51):1-5. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

  12. Understanding and preventing vaccination errors. | PSNet

    psnet.ahrq.gov/issue/understanding-and-preventing-vaccination-errors
    April 15, 2016 - Study Understanding and preventing vaccination errors. Citation Text: Poiraud C, Réthoré L, Bourdon O, et al. Understanding and preventing vaccination errors. Infect Dis Now. 2023;53(2):104641. doi:10.1016/j.idnow.2023.01.001. Copy Citation Format: DOI Google Scholar BibTeX…

  13. Aiming higher to enhance professionalism: beyond accreditation and certification. | PSNet

    psnet.ahrq.gov/issue/aiming-higher-enhance-professionalism-beyond-accreditation-and-certification
    February 03, 2011 - Commentary Aiming higher to enhance professionalism: beyond accreditation and certification. Citation Text: Chassin MR, Baker DW. Aiming higher to enhance professionalism: beyond accreditation and certification. JAMA. 2015;313(18):1795-6. doi:10.1001/jama.2015.3818. Copy Citation F…

  14. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. | PSNet

    psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm
    June 21, 2016 - Book/Report RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Citation Text: RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015. Copy Citation Save Save to your library Print …

  15. Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients. | PSNet

    psnet.ahrq.gov/issue/quality-improvement-and-patient-care-checklists-intrahospital-transfers-involving-pediatric
    September 23, 2020 - Study Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients. Citation Text: Nakayama DK, Lester SS, Rich DR, et al. Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients.…

  16. Technical mistakes during the acquisition of the electrocardiogram. | PSNet

    psnet.ahrq.gov/issue/technical-mistakes-during-acquisition-electrocardiogram
    March 09, 2022 - Review Technical mistakes during the acquisition of the electrocardiogram. Citation Text: García-Niebla J, Llontop-García P, Valle-Racero JI, et al. Technical mistakes during the acquisition of the electrocardiogram. Ann Noninvasive Electrocardiol. 2009;14(4):389-403. doi:10.1111/j.154…

  17. Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims. | PSNet

    psnet.ahrq.gov/issue/cognitive-errors-and-logistical-breakdowns-contributing-missed-and-delayed-diagnoses-breast
    March 02, 2011 - Study Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims. Citation Text: Poon EG, Kachalia A, Puopolo AL, et al. Cognitive errors and logistical breakdowns contributin…

  18. Psychology insights on apologizing to patients. | PSNet

    psnet.ahrq.gov/issue/psychology-insights-apologizing-patients
    March 27, 2024 - Commentary Psychology insights on apologizing to patients. Citation Text: Redelmeier DA, Roach J. Psychology insights on apologizing to patients. J Hosp Med. 2024;Epub Dec 30. doi:10.1002/jhm.13585. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…

  19. Factors associated with diagnostic error: an analysis of closed medical malpractice claims. | PSNet

    psnet.ahrq.gov/issue/factors-associated-diagnostic-error-analysis-closed-medical-malpractice-claims
    July 13, 2022 - Study Factors associated with diagnostic error: an analysis of closed medical malpractice claims. Citation Text: Grenon V, Szymonifka J, Adler-Milstein J, et al. Factors associated with diagnostic error: an analysis of closed medical malpractice claims. J Patient Saf. 2023;19(3):211-215.…

  20. Support methods for healthcare professionals who are second victims: an integrative review. | PSNet

    psnet.ahrq.gov/issue/support-methods-healthcare-professionals-who-are-second-victims-integrative-review
    April 27, 2022 - Review Support methods for healthcare professionals who are second victims: an integrative review. Citation Text: Support methods for healthcare professionals who are second victims: an integrative review. Neft MW, Sekula K, Zoucha R, et al. AANA J. 2022;90(3):189-196.  Copy Cit…
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