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psnet.ahrq.gov/issue/analysis-academic-medical-centers-corrective-action-plan-response-fatal-medication-error
February 21, 2018 - Commentary
Analysis of an academic medical center’s corrective action plan in response to fatal medication error using the Institute for Safe Medication Practices’ Hierarchy of Effectiveness.
Citation Text:
Stolte AR, Siwy YM, Tanios SB, et al. Analysis of an academic medical center’s co…
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psnet.ahrq.gov/issue/automated-adverse-event-detection-collaborative-electronic-adverse-event-identification
July 03, 2016 - Study
Automated adverse event detection collaborative: electronic adverse event identification, classification, and corrective actions across academic pediatric institutions.
Citation Text:
Stockwell DC, Kirkendall E, Muething S, et al. Automated adverse event detection collaborative: e…
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psnet.ahrq.gov/node/60268/psn-pdf
April 29, 2020 - Flow to device correctly adjusted accordingly, if applicable
ii. … Flow – is sweep-gas flow correctly adjusted?
ii.
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psnet.ahrq.gov/issue/outcomes-overlapping-surgery-large-academic-medical-center
May 03, 2023 - Study
Outcomes with overlapping surgery at a large academic medical center.
Citation Text:
Ponce BA, Wills BW, Hudson PW, et al. Outcomes With Overlapping Surgery at a Large Academic Medical Center. Ann Surg. 2019;269(3):465-470. doi:10.1097/SLA.0000000000002701.
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psnet.ahrq.gov/issue/postoperative-complications-due-retained-surgical-sponge
February 23, 2011 - Commentary
Postoperative complications due to a retained surgical sponge.
Citation Text:
Sarda AK, Pandey D, Neogi S, et al. Postoperative complications due to a retained surgical sponge. Singapore Med J. 2007;48(6):e160-4.
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psnet.ahrq.gov/node/42822/psn-pdf
December 18, 2013 - Automated adverse event detection collaborative:
electronic adverse event identification, classification, and
corrective actions across academic pediatric institutions.
December 18, 2013
Stockwell DC, Kirkendall E, Muething S, et al. Automated adverse event detection collaborative: electronic
adverse event identif…
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psnet.ahrq.gov/node/36555/psn-pdf
January 05, 2017 - Registration-associated patient misidentification in an
academic medical center: causes and corrections.
January 5, 2017
Bittle MJ, Charache P, Wassilchalk DM. Registration-associated patient misidentification in an academic
medical center: causes and corrections. Jt Comm J Qual Patient Saf. 2007;33(1):25-33.
doi:…
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psnet.ahrq.gov/node/49778/psn-pdf
December 01, 2016 - Further review revealed that the information about the positive yeast culture had been correctly called
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - back instructions and receiving confirmation, is recommended to assure that all messages have been correctly
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psnet.ahrq.gov/node/44518/psn-pdf
January 22, 2016 - Embracing errors in simulation-based training: the effect
of error training on retention and transfer of central
venous catheter skills.
January 22, 2016
Gardner AK, Abdelfattah K, Wiersch J, et al. Embracing Errors in Simulation-Based Training: The Effect of
Error Training on Retention and Transfer of Central Ven…
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psnet.ahrq.gov/issue/evaluation-perioperative-medication-errors-and-adverse-drug-events
July 16, 2019 - Study
Classic
Evaluation of perioperative medication errors and adverse drug events.
Citation Text:
Nanji KC, Patel A, Shaikh S, et al. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology. 2016;124(1):25-34. doi:10.1097/ALN.0000…
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psnet.ahrq.gov/issue/evaluation-wound-photography-remote-postoperative-assessment-surgical-site-infections
July 03, 2014 - Study
Evaluation of wound photography for remote postoperative assessment of surgical site infections.
Citation Text:
Broman KK, Gaskill CE, Faqih A, et al. Evaluation of Wound Photography for Remote Postoperative Assessment of Surgical Site Infections. JAMA Surg. 2019;154(2):117-124. do…
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psnet.ahrq.gov/issue/why-isnt-time-out-being-implemented-exploratory-study
May 04, 2010 - Study
Why isn't 'time out' being implemented? An exploratory study.
Citation Text:
Gillespie BM, Chaboyer W, Wallis M, et al. Why isn't 'time out' being implemented? An exploratory study. Qual Saf Health Care. 2010;19(2):103-6. doi:10.1136/qshc.2008.030593.
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psnet.ahrq.gov/issue/5th-anniversary-universal-protocol-pitfalls-and-pearls-revisited
December 21, 2014 - Commentary
The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited.
Citation Text:
Stahel PF, Mehler PS, Clarke TJ, et al. The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited. Patient Saf Surg. 2009;3(1):14. doi:10.1186/1754-9493-3-14. …
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psnet.ahrq.gov/issue/protecting-patients-unsafe-system-etiology-and-recovery-intraoperative-deviations-care
October 19, 2012 - Study
Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.
Citation Text:
Hu Y-Y, Arriaga AF, Roth EM, et al. Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. Ann Surg. 2012;…
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psnet.ahrq.gov/issue/role-surgeon-error-withdrawal-postoperative-life-support
July 03, 2014 - Study
The role of surgeon error in withdrawal of postoperative life support.
Citation Text:
Schwarze ML, Redmann AJ, Brasel KJ, et al. The role of surgeon error in withdrawal of postoperative life support. Ann Surg. 2012;256(1):10-5. doi:10.1097/SLA.0b013e3182580de5.
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…
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psnet.ahrq.gov/issue/management-difficult-airway-closed-claims-analysis
July 13, 2010 - Study
Management of the difficult airway: a closed claims analysis.
Citation Text:
Peterson GN, Domino KB, Caplan RA, et al. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005;103(1):33-39.
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psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
February 22, 2017 - observing and directing the execution of tasks or activities and making certain that everything is done correctly … observing and directing the execution of tasks or activities and making certain that everything is done correctly
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psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
February 01, 2004 - , the clinical evaluation is performed well, appropriate tests are ordered, the tests are performed correctly … The clinician must see the test result, interpret it correctly, and determine an appropriate response
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psnet.ahrq.gov/node/867651/psn-pdf
February 26, 2025 - systems resulting in success and systems resulting in
failure function via two distinct modes: either correctly … within the sociotechnical system.4,19 In this way, every individual part of a system may function correctly