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  1. Evaluating an evidence-based bundle for preventing surgical site infection. | PSNet

    psnet.ahrq.gov/issue/evaluating-evidence-based-bundle-preventing-surgical-site-infection
    August 21, 2019 - Study Evaluating an evidence-based bundle for preventing surgical site infection. Citation Text: Anthony T, Murray BW, Sum-Ping JT, et al. Evaluating an evidence-based bundle for preventing surgical site infection: a randomized trial. Arch Surg. 2011;146(3):263-9. doi:10.1001/archsurg.20…

  2. Low perfusion and missed diagnosis of hypoxemia by pulse oximetry in darkly pigmented skin: a prospective study. | PSNet

    psnet.ahrq.gov/issue/low-perfusion-and-missed-diagnosis-hypoxemia-pulse-oximetry-darkly-pigmented-skin-prospective
    March 14, 2022 - Study Low perfusion and missed diagnosis of hypoxemia by pulse oximetry in darkly pigmented skin: a prospective study. Citation Text: Gudelunas MK, Lipnick M, Hendrickson C, et al. Low perfusion and missed diagnosis of hypoxemia by pulse oximetry in darkly pigmented skin: a prospective s…

  3. Medication histories in critically ill patients completed by pharmacy personnel. | PSNet

    psnet.ahrq.gov/issue/medication-histories-critically-ill-patients-completed-pharmacy-personnel
    September 23, 2020 - Study Medication histories in critically ill patients completed by pharmacy personnel. Citation Text: Kram BL, Trammel MA, Kram SJ, et al. Medication histories in critically ill patients completed by pharmacy personnel. Ann Pharmacother. 2019;53(6):596-602. doi:10.1177/1060028018825483. …

  4. How to make medication error reporting systems work—factors associated with their successful development and implementation. | PSNet

    psnet.ahrq.gov/issue/how-make-medication-error-reporting-systems-work-factors-associated-their-successful
    December 05, 2012 - Study How to make medication error reporting systems work—factors associated with their successful development and implementation. Citation Text: Holmström A-R, Laaksonen R, Airaksinen M. How to make medication error reporting systems work--Factors associated with their successful develo…

  5. National and local medication error reporting systems—a survey of practices in 16 countries. | PSNet

    psnet.ahrq.gov/issue/national-and-local-medication-error-reporting-systems-survey-practices-16-countries
    September 09, 2015 - Study National and local medication error reporting systems—a survey of practices in 16 countries. Citation Text: Holmström A-R, Airaksinen M, Weiss M, et al. National and local medication error reporting systems: a survey of practices in 16 countries. J Patient Saf. 2012;8(4):165-76. …

  6. Contextual factors influencing the implementation of a multifaceted intervention to improve teamwork and quality for hospitalized patients: a multi-site qualitative comparative case study. | PSNet

    psnet.ahrq.gov/issue/contextual-factors-influencing-implementation-multifaceted-intervention-improve-teamwork-and
    November 15, 2023 - Study Contextual factors influencing the implementation of a multifaceted intervention to improve teamwork and quality for hospitalized patients: a multi-site qualitative comparative case study. Citation Text: Terwilliger IA, Johnson JK, Manojlovich M, et al. Contextual Factors Influenci…

  7. Use of error management theory to quantify and characterize residents' error recovery strategies. | PSNet

    psnet.ahrq.gov/issue/use-error-management-theory-quantify-and-characterize-residents-error-recovery-strategies
    June 14, 2023 - Study Use of error management theory to quantify and characterize residents' error recovery strategies. Citation Text: Pugh CM, Law KE, Cohen ER, et al. Use of error management theory to quantify and characterize residents’ error recovery strategies. Am J Surg. 2020;219(2):214-220. doi:1…

  8. An exploratory study of knowledge brokering in hospital settings: facilitating knowledge sharing and learning for patient safety? | PSNet

    psnet.ahrq.gov/issue/exploratory-study-knowledge-brokering-hospital-settings-facilitating-knowledge-sharing-and
    July 02, 2008 - Study An exploratory study of knowledge brokering in hospital settings: facilitating knowledge sharing and learning for patient safety? Citation Text: Waring J, Currie G, Crompton A, et al. An exploratory study of knowledge brokering in hospital settings: facilitating knowledge sharing …

  9. Validation and use of the Second Victim Experience and Support Tool questionnaire: a scoping review. | PSNet

    psnet.ahrq.gov/issue/validation-and-use-second-victim-experience-and-support-tool-questionnaire-scoping-review
    July 09, 2008 - Review Validation and use of the Second Victim Experience and Support Tool questionnaire: a scoping review. Citation Text: Dato Md Yusof YJ, Ng QX, Teoh SE, et al. Validation and use of the Second Victim Experience and Support Tool questionnaire: a scoping review. Public Health. 2023;223…

  10. Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs. | PSNet

    psnet.ahrq.gov/issue/pilot-implementation-perioperative-protocol-guide-operating-room-intensive-care-unit-patient
    January 03, 2017 - Study Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs. Citation Text: Petrovic MA, Aboumatar HJ, Baumgartner WA, et al. Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patie…

  11. Cardiac surgery errors: results from the UK National Reporting and Learning System. | PSNet

    psnet.ahrq.gov/issue/cardiac-surgery-errors-results-uk-national-reporting-and-learning-system
    May 24, 2012 - Study Cardiac surgery errors: results from the UK National Reporting and Learning System. Citation Text: Martinez EA, Shore AD, Colantuoni E, et al. Cardiac surgery errors: results from the UK National Reporting and Learning System. Int J Qual Health Care. 2011;23(2):151-8. doi:10.1093/i…

  12. DEEP SCOPE: a framework for safe healthcare design. | PSNet

    psnet.ahrq.gov/issue/deep-scope-framework-safe-healthcare-design
    August 18, 2021 - Commentary DEEP SCOPE: a framework for safe healthcare design. Citation Text: Taylor E, Hignett S. DEEP SCOPE: a framework for safe healthcare design. Int J Environ Res Public Health. 2021;18(15):7780. doi:10.3390/ijerph18157780. Copy Citation Format: DOI Google Scholar Bib…

  13. Crew resource management training in the intensive care unit. A multisite controlled before-after study. | PSNet

    psnet.ahrq.gov/issue/crew-resource-management-training-intensive-care-unit-multisite-controlled-after-study
    July 10, 2013 - Study Crew resource management training in the intensive care unit. A multisite controlled before-after study. Citation Text: Kemper PF, de Bruijne M, van Dyck C, et al. Crew resource management training in the intensive care unit. A multisite controlled before-after study. BMJ Qual Saf.…

  14. Is researching adverse events in hospital deaths a good way to describe patient safety in hospitals: a retrospective patient record review study. | PSNet

    psnet.ahrq.gov/issue/researching-adverse-events-hospital-deaths-good-way-describe-patient-safety-hospitals
    March 18, 2013 - Study Is researching adverse events in hospital deaths a good way to describe patient safety in hospitals: a retrospective patient record review study. Citation Text: Baines RJ, Langelaan M, de Bruijne M, et al. Is researching adverse events in hospital deaths a good way to describe pati…

  15. Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry. | PSNet

    psnet.ahrq.gov/issue/medication-error-reporting-and-pharmacy-resident-experience-during-implementation
    November 17, 2010 - Study Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry. Citation Text: Weant KA, Cook AM, Armitstead JA. Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber …

  16. What are the safety risks for patients undergoing treatment by multiple specialties: a retrospective patient record review study. | PSNet

    psnet.ahrq.gov/issue/what-are-safety-risks-patients-undergoing-treatment-multiple-specialties-retrospective
    March 18, 2013 - Study What are the safety risks for patients undergoing treatment by multiple specialties: a retrospective patient record review study. Citation Text: Baines RJ, de Bruijne M, Langelaan M, et al. What are the safety risks for patients undergoing treatment by multiple specialties: a retr…

  17. Analysis of risk factors for patient safety events occurring in the emergency department. | PSNet

    psnet.ahrq.gov/issue/analysis-risk-factors-patient-safety-events-occurring-emergency-department
    January 26, 2022 - Study Analysis of risk factors for patient safety events occurring in the emergency department. Citation Text: Alsabri M, Boudi Z, Zoubeidi T, et al. Analysis of risk factors for patient safety events occurring in the emergency department. J Patient Saf. 2022;18(1):e124-e135. doi:10.1097…

  18. Electronic alerts to prevent venous thromboembolism among hospitalized patients. | PSNet

    psnet.ahrq.gov/issue/electronic-alerts-prevent-venous-thromboembolism-among-hospitalized-patients
    October 19, 2022 - Study Classic Electronic alerts to prevent venous thromboembolism among hospitalized patients. Citation Text: Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005;352(10):969-77. …

  19. The good, the bad, and the ugly: operative staff perspectives of surgeon coping with intraoperative errors. | PSNet

    psnet.ahrq.gov/issue/good-bad-and-ugly-operative-staff-perspectives-surgeon-coping-intraoperative-errors
    September 22, 2021 - Study The good, the bad, and the ugly: operative staff perspectives of surgeon coping with intraoperative errors. Citation Text: D’Angelo A-LD, Kapur N, Kelley SR, et al. The good, the bad, and the ugly: operative staff perspectives of surgeon coping with intraoperative errors. Surgery. …

  20. A quality improvement initiative to improve patient safety event reporting by residents. | PSNet

    psnet.ahrq.gov/issue/quality-improvement-initiative-improve-patient-safety-event-reporting-residents
    March 08, 2023 - Study A quality improvement initiative to improve patient safety event reporting by residents. Citation Text: Herchline D, Rojas C, Shah AA, et al. A quality improvement initiative to improve patient safety event reporting by residents. Pediatr Qual Saf. 2022;7(1):e519. doi:10.1097/pq9.0…
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