-
psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis
Patrice Spath, BA, RHIT, and William Minogue, MD | July 1, 2008
View more articles from the same authors.
Citation Text:
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause …
-
psnet.ahrq.gov/issue/embracing-errors-simulation-based-training-effect-error-training-retention-and-transfer
May 23, 2013 - Study
Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills.
Citation Text:
Gardner AK, Abdelfattah K, Wiersch J, et al. Embracing Errors in Simulation-Based Training: The Effect of Error Training on Retent…
-
psnet.ahrq.gov/issue/identifying-risk-use-tumor-markers-improve-patient-safety
March 09, 2022 - Study
Identifying risk in the use of tumor markers to improve patient safety.
Citation Text:
Moreno-Campoy EE, De la Torre FJM-, Martos-Crespo F, et al. Identifying risk in the use of tumor markers to improve patient safety. Clin Chem Lab Med. 2016;54(12):1947-1953. doi:10.1515/cclm-2015…
-
psnet.ahrq.gov/issue/call-application-patient-safety-culture-medical-humanitarian-action-literature-review
February 10, 2021 - Review
A call for the application of patient safety culture in medical humanitarian action: a literature review.
Citation Text:
Biquet J-M, Schopper D, Sprumont D, et al. A call for the application of patient safety culture in medical humanitarian action: a literature review. J Patient S…
-
psnet.ahrq.gov/issue/predictors-likelihood-speaking-about-safety-concerns-labour-and-delivery
October 19, 2022 - Study
Predictors of likelihood of speaking up about safety concerns in labour and delivery.
Citation Text:
Lyndon A, Sexton B, Simpson KR, et al. Correction. BMJ Qual Saf. 2011;22(2):791-799. doi:10.1136/bmjqs.2010.050211.
Copy Citation
Format:
DOI Google Scholar BibTeX E…
-
psnet.ahrq.gov/node/866205/psn-pdf
July 10, 2024 - Hemorrhagic Shock after Elective Spine Surgery: Failure
to Rescue after Limited Response to Nursing Concerns.
July 10, 2024
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response
to Nursing Concerns. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hemorrhagic-sh…
-
psnet.ahrq.gov/node/50584/psn-pdf
October 23, 2019 - Unprotected: broken promises in Georgia’s senior care
industry.
October 23, 2019
Schrade B, Teegardin C. Atlanta Journal-Constitution. Sept-October 2019.
https://psnet.ahrq.gov/issue/unprotected-broken-promises-georgias-senior-care-industry
Assisted living facilities have challenges that reduce the quality and saf…
-
psnet.ahrq.gov/issue/learning-near-misses-quick-fixes-closing-swiss-cheese-holes
April 11, 2012 - Study
Learning from near misses: from quick fixes to closing off the Swiss-cheese holes.
Citation Text:
Jeffs L, Berta W, Lingard LA, et al. Learning from near misses: from quick fixes to closing off the Swiss-cheese holes. BMJ Qual Saf. 2012;21(4):287-94. doi:10.1136/bmjqs-2011-000256…
-
psnet.ahrq.gov/issue/structural-empowerment-and-patient-safety-culture-among-registered-nurses-working-adult
January 23, 2008 - Study
Structural empowerment and patient safety culture among registered nurses working in adult critical care units.
Citation Text:
Armellino D, Griffin MTQ, Fitzpatrick JJ. Structural empowerment and patient safety culture among registered nurses working in adult critical care units.…
-
psnet.ahrq.gov/issue/nursing-interruptions-trauma-intensive-care-unit-prospective-observational-study
November 09, 2016 - Study
Nursing interruptions in a trauma intensive care unit: a prospective observational study.
Citation Text:
Craker NC, Myers RA, Eid J, et al. Nursing Interruptions in a Trauma Intensive Care Unit: A Prospective Observational Study. J Nurs Adm. 2017;47(4):205-211. doi:10.1097/NNA.0000…
-
psnet.ahrq.gov/node/49462/psn-pdf
October 01, 2004 - Thin Air
October 1, 2004
Gaba DM. Thin Air. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/thin-air
Case Objectives
Identify the gas-specific non-interchangeable connectors used for bulk gas supply outlets in
hospitals.
Define forcing function, both in engineered safety devices and in human procedures.
R…
-
psnet.ahrq.gov/issue/he-thought-lady-door-was-lady-window-qualitative-study-patient-identification-practices
June 14, 2017 - Study
He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices.
Citation Text:
Phipps E, Turkel M, Mackenzie ER, et al. He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identifica…
-
psnet.ahrq.gov/node/49494/psn-pdf
January 01, 2006 - The oral
prednisone was stopped, and the patient was correctly given a gram of intravenous methylprednisolone
-
psnet.ahrq.gov/web-mm/misplaced-vial-medication-kit-variability-contributes-medication-error-during-patient
March 12, 2021 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport
Citation Text:
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Q…
-
psnet.ahrq.gov/node/60172/psn-pdf
March 01, 2021 - Verification Screen That Includes Prominent Patient
Photograph Significantly Reduces Errors Caused by
Orders Placed in Wrong Chart
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-
reduc…
-
psnet.ahrq.gov/issue/effect-executive-walk-rounds-nurse-safety-climate-attitudes-randomized-trial-clinical-units
June 16, 2011 - Study
Classic
The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical units.
Citation Text:
Thomas EJ, Sexton B, Neilands TB, et al. The effect of executive walk rounds on nurse safety climate attitudes: a randomiz…
-
psnet.ahrq.gov/issue/accuracy-send-out-test-ordering-college-american-pathologists-q-probes-study-ordering
November 12, 2008 - Study
Accuracy of send-out test ordering: a College of American Pathologists Q-Probes study of ordering accuracy in 97 clinical laboratories.
Citation Text:
Valenstein PN, Walsh MK, Stankovic AK. Accuracy of send-out test ordering: a College of American Pathologists Q-Probes study of o…
-
psnet.ahrq.gov/issue/preanalytical-errors-primary-healthcare-questionnaire-study-information-search-procedures
July 07, 2010 - Study
Preanalytical errors in primary healthcare: a questionnaire study of information search procedures, test request management and test tube labelling.
Citation Text:
Söderberg J, Brulin C, Grankvist K, et al. Preanalytical errors in primary healthcare: a questionnaire study of info…
-
psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
August 05, 2022 - Duplicate Therapies in Retail Pharmacy
Citation Text:
Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Citation
Format:
Google Scholar BibTeX E…
-
psnet.ahrq.gov/node/36129/psn-pdf
September 29, 2010 - Otolaryngologists' responses to errors and adverse
events.
September 29, 2010
Lander LI, Connor JA, Shah RK, et al. Otolaryngologists' responses to errors and adverse events.
Laryngoscope. 2006;116(7):1114-20.
https://psnet.ahrq.gov/issue/otolaryngologists-responses-errors-and-adverse-events
The investigators sur…