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psnet.ahrq.gov/issue/effect-facility-complexity-perceptions-safety-climate-operating-room-size-matters
December 21, 2014 - Study
The effect of facility complexity on perceptions of safety climate in the operating room: size matters.
Citation Text:
Carney BT, West P, Neily J, et al. The effect of facility complexity on perceptions of safety climate in the operating room: size matters. Am J Med Qual. 2010;25…
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psnet.ahrq.gov/issue/enhancing-patient-safety-national-standard-cyber-resiliency-healthcare
September 23, 2020 - Commentary
Enhancing patient safety: a national standard for cyber resiliency in healthcare.
Citation Text:
Samuelson-Kiraly C, Mitchell JI, Kingston D, et al. Enhancing patient safety: A national standard for cyber resiliency in healthcare. Healthc Manage Forum. 2024;37(1):9-12. doi:10.…
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psnet.ahrq.gov/issue/improving-shared-situation-awareness-high-risk-therapies-hospitalized-children
October 20, 2021 - Study
Improving shared situation awareness for high-risk therapies in hospitalized children.
Citation Text:
Sosa T, Mayer B, Chakkalakkal B, et al. Improving shared situation awareness for high-risk therapies in hospitalized children. Hosp Pediatr. 2022;12(1):37-46. doi:10.1542/hpeds.202…
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psnet.ahrq.gov/issue/sustaining-and-spreading-reduction-adverse-drug-events-multicenter-collaborative
November 16, 2022 - Study
Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.
Citation Text:
Tham E, Calmes HM, Poppy A, et al. Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative. Pediatrics. 2011;128(2):e438-45. doi:10.1542…
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psnet.ahrq.gov/issue/quality-framework-remote-antenatal-care-qualitative-study-women-healthcare-professionals-and
October 21, 2020 - Study
Quality framework for remote antenatal care: qualitative study with women, healthcare professionals and system-level stakeholders.
Citation Text:
Hinton L, Dakin FH, Kuberska K, et al. Quality framework for remote antenatal care: qualitative study with women, healthcare professiona…
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psnet.ahrq.gov/issue/early-diagnostic-suggestions-improve-accuracy-family-physicians-randomized-controlled-trial
April 07, 2021 - Study
Early diagnostic suggestions improve accuracy of family physicians: a randomized controlled trial in Greece.
Citation Text:
Kostopoulou O, Lionis C, Angelaki A, et al. Early diagnostic suggestions improve accuracy of family physicians: a randomized controlled trial in Greece. Fam P…
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psnet.ahrq.gov/issue/experiences-and-perceptions-healthcare-stakeholders-disclosing-errors-and-adverse-events
July 31, 2024 - Study
Experiences and perceptions of healthcare stakeholders in disclosing errors and adverse events to historically marginalized patients.
Citation Text:
Olazo K, Gallagher TH, Sarkar U. Experiences and perceptions of healthcare stakeholders in disclosing errors and adverse events to hi…
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psnet.ahrq.gov/issue/scoping-review-distributed-cognition-acute-care-clinical-decision-making
April 08, 2020 - Review
A scoping review of distributed cognition in acute care clinical decision-making.
Citation Text:
Wilson E, Daniel M, Rao A, et al. A scoping review of distributed cognition in acute care clinical decision-making. Diagnosis (Berl). 2023;10(2):68-88. doi:10.1515/dx-2022-0095.
Copy…
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psnet.ahrq.gov/issue/systematic-review-workplace-triggers-emotions-healthcare-environment-emotions-experienced-and
July 05, 2023 - Review
A systematic review of workplace triggers of emotions in the healthcare environment, the emotions experienced, and the impact on patient safety.
Citation Text:
Sattar R, Lawton R, Janes G, et al. A systematic review of workplace triggers of emotions in the healthcare environment, …
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psnet.ahrq.gov/issue/redesigning-rounds-towards-more-purposeful-approach-inpatient-teaching-and-learning
February 02, 2022 - Commentary
Redesigning rounds: towards a more purposeful approach to inpatient teaching and learning.
Citation Text:
Reilly JB, Bennett N, Fosnocht K, et al. Redesigning rounds: towards a more purposeful approach to inpatient teaching and learning. Acad Med. 2015;90(4):450-3. doi:10.1097…
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psnet.ahrq.gov/issue/partnership-pathway-diagnostic-excellence-challenges-and-successes-implementing-safer-dx
April 13, 2022 - Study
Partnership as a pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning Lab.
Citation Text:
Sloane J, Singh H, Upadhyay DK, et al. Partnership as a pathway to diagnostic excellence: the challenges and successes of implementing the Safer…
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psnet.ahrq.gov/issue/register-based-research-adverse-events-revealing-incomplete-records-threatening-patient
October 06, 2021 - Review
Register-based research of adverse events revealing incomplete records threatening patient safety.
Citation Text:
Kinnunen U-M, Kivekäs E, Palojoki S, et al. Register-based research of adverse events revealing incomplete records threatening patient safety. Stud Health Technol Info…
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psnet.ahrq.gov/issue/impact-pharmacist-interventions-medication-errors-hospitalized-pediatric-patients-systematic
August 04, 2021 - Review
Impact of pharmacist interventions on medication errors in hospitalized pediatric patients: a systematic review and meta-analysis.
Citation Text:
Naseralallah LM, Hussain TA, Jaam M, et al. Impact of pharmacist interventions on medication errors in hospitalized pediatric patients:…
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psnet.ahrq.gov/issue/errors-breast-imaging-how-reduce-errors-and-promote-safety-environment
July 22, 2020 - Commentary
Errors in breast imaging: how to reduce errors and promote a safety environment.
Citation Text:
Sivarajah R, Dinh ML, Chetlen A. Errors in breast imaging: how to reduce errors and promote a safety environment. J Breast Imaging. 2021;3(2):221-230. doi:10.1093/jbi/wbaa118.
Cop…
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psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Rethinking Root Cause Analysis
January 1, 2016
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
Annual Perspective 2016
Introduction
Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
May 01, 2012 - Spotlight Case July 2008
Spotlight Case
The Perils of Cross Coverage
*
*
Source and Credits
This presentation is based on the May 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …
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psnet.ahrq.gov/node/33621/psn-pdf
November 01, 2005 - Rapid Response Teams: Lessons from the Early
Experience
November 1, 2005
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
Perspective
Health care organizations throughout the world have ide…
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psnet.ahrq.gov/node/49473/psn-pdf
March 01, 2005 - On O.R. Off?
March 1, 2005
Leonard M. On O.R. Off? PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/or
The Case
An elderly man was admitted to the vascular surgery service with rest pain in his leg. Angiography
demonstrated peripheral artery disease with anatomy suitable for revascularization. A consulting
…
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psnet.ahrq.gov/node/33835/psn-pdf
June 01, 2017 - In Conversation With… Paul Aylin, MBChB
June 1, 2017
In Conversation With… Paul Aylin, MBChB. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
Editor's note: Professor Aylin is Professor of Epidemiology and Public Health at Imperial College London,
where he is also Co-Direc…
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psnet.ahrq.gov/node/33741/psn-pdf
November 01, 2012 - The Evidence-Based Physical Examination as a Patient
Safety Practice
November 1, 2012
McGee S. The Evidence-Based Physical Examination as a Patient Safety Practice. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/evidence-based-physical-examination-patient-safety-practice
Perspective
Near the end of hi…